International Scholars Program Application

North American Sponsor

Name(Required)

First Last

Title(Required)

Institutional Affiliation(Required)

Address(Required)

Phone(Required)

FAX #

Email(Required)

Applicant

Name(Required)

First Last

Title(Required)

Institutional Affiliation(Required)

Address(Required)

Phone(Required)

FAX #

Email(Required)

Date of Birth(Required)

Applicant CV Upload (English) (PDF Only)(Required)

Max. file size: 128 MB.

Applicant Bibliography Upload (PDF Only)(Required)

Max. file size: 128 MB.

Applicant Current Position and Academic Title, With Dates Held(Required)

Describe the principal professional activities of the applicant, indicating approximate % of time devoted to: (1) teaching (2) clinical research (3) laboratory research (4) patient care (5) administration(Required)

Beginning at completion of high school, list in chronological order, the applicant’s formal education and past positions (following completion of training). Indicate dates positions were held(Required)

List all trips the applicant has made to North America in the past 10 years. Indicate dates of trip, duration, purpose, and sponsor(Required)

Indicate which of the following applies to this applicant:(Required)

Speaks English fluently

Speaks English less than fluently

Reads English, but has difficulty with spoken English

Plan for use of the award (attach separate page): In 300-400 words, the applicant should describe the goals of the visit in the sponsor’s unit. Describe the proposed activities of the scholar during the proposed visit. Indicate whether the scholar has had previous contact and collaboration with the sponsor. Indicate the proposed duration of the visit and the approximate dates.(Required)

Max. file size: 128 MB.

Letter of support from the sponsor (attachment): This letter should provide information on how the proposed program will benefit the scholar and the scholar’s endocrine unit, indicate whether additional financial resources for support of the scholar are available if needed, and provide any other details that support the scholar’s application.(Required)

Max. file size: 128 MB.

North American Sponsor

Applicant

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