Last name first name proposed case affiliation

Please Print LAST NAME FIRST NAME Proposed CASE Affiliation

^ THIS APPLICATION MAY BE DUPLICATED AND IS FREE OF CHARGE.


1. NAME Please print your name in Latin letters (as it appears on your international passport if you have one). Do not translate. .


____________________________________________________________________________________________________

Last Name First Name Middle Name or Patronymic


2. GENDER (please circle one): Male Female


3. CITIZENSHIP ___________________________________


Attach recent photo
4. AGE _______ ^ 5. DATE OF BIRTH_____/______/________

Month Day Year


6. PLACE OF BIRTH

city: _____________________­­­ country:___________________


7. MAILING ADDRESS (the address at which you receive your mail) ____________________________________________________________________________________________________

Country City Postal Index

____________________________________________________________________________________________________

Street Name House/Apartment Number

(_________) _______________ _______________________ _____________________________________

City code Telephone (home) Another contact telephone E-mail address


8. disability ___yes ___no

Information for statistical and logistic purposes only; answer will not affect the outcome of your application. If yes, please describe your disability (i.e. hearing impaired, visually impaired, etc.)

_________________________________________________________________________________________

_________________________________________________________________________________________


^ 9. international passport number (if applicable)

_________________________________________________________________

10. current work address in english


_________________________________________________________________________________________________________

Name of Institute or Organization Type of Organization

_________________________________________________________________________________________________________

Professional Title Department

_________________________________________________________________________________________________________

Country City Postal Index

(_________) _________________ _______________________ __________________________________________

City code Telephone (work) Fax E-mail address


^ 11. your specialization or subfield _______________________________________________________________________________________


12. title of proposal

Please be as descriptive and specific as possible. If selected, the title of your proposal will be extremely important in arranging your placement.

_________________________________________________________________________________________


__________________________________________________________________________________________________________


^ 13. provide a brief summary of your research proposal

Please limit your summary to 30 words or less. Your full five to seven page proposal should be attached to this application.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________


^ 14. proposed u.s. university/organization affiliation

Please list universities in order of preference. Please list contact information (professor’s name, phone and e-mail address) whenever possible. We cannot guarantee your preference for placement.


________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________


15. Carnegie Research Fellows are often asked by their host universities to take part in discussions, such as graduate seminars, related to their fields. From time to time, they are also asked to speak about current social, political and economic situation in Russia, Russian views of America, and similar more general topics. Are you willing to take part in activities such as these? Are there particular issues or subjects that you would be interested in speaking about? ___yes ___no


If yes, please name them.


____________________________________________________________________________________________________________________________________________________________________________________

^ 16. educational background

Please list all institutions attended after school. Do not translate degree titles.


University Name and Location Field of Study Dates Degree & Date Received

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

^ 17. provide your employment history in reverse chronological order

Include the past ten years.


Job Title Employer Name Address Dates


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


^ 18. list courses taught or currently teaching, and approximate number of students that you

teach each year

____________________________________________________________________________________


____________________________________________________________________________________


^ 19. list publications in scholarly journals/periodicals in reverse chronological order

Do not translate titles.

Article or Monograph Title Publisher & City Year


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


^ 20. indicate any academic or professional honors received, including dates

____________________________________________________________________________________


____________________________________________________________________________________


^ 21. list professional activities

Please include affiliations, significant honors, and accomplishments.


____________________________________________________________________________________


____________________________________________________________________________________


____________________________________________________________________________________


^ 22. knowledge of english and other languages


Native Language: _________________________


Beginning with English, list all languages you know and rate your reading, writing, listening, and speaking skills in each language, using Excellent, Good, Fair, and Poor.


Language Reading Writing Listening Speaking


1. ENGLISH __________________________________________________________________________________


2.____________________________________________________________________________________________

3.____________________________________________________________________________________________


4.____________________________________________________________________________________________


23. toefl testing. If you have taken the Test of English as a Foreign Language (TOEFL), please give the date and location where you took the examination, and your scores. If you have a copy of the test scores, please attach a photocopy of your score reports to this application. (The TOEFL is NOT required for applicants to the CRFP.)


______________________________________________________________________________________________


______________________________________________________________________________________________


^ 24. current english training (optional): Describe what you are doing now or plan to do to increase your English-language proficiency.


______________________________________________________________________________________________


______________________________________________________________________________________________


^ 25. travel abroad for the last five years (Please give year and place)


______________________________________________________________________________________________


______________________________________________________________________________________________


______________________________________________________________________________________________


^ 26. u.s. tax information


a. If you have ever received a Social Security number or Tax Identification Number from the U.S. government, please list:

________ - _____ - ________


b. If you have neither of the aforementioned numbers, please provide the following information for tax purposes:


________________________________________________________________________

Mother’s maiden (before marriage) last name, first name, middle name or patronymic.


________________________________________________________________________

Father’s last name, first name, middle name or patronymic.


CERTIFICATION: I certify that the information given in this application is complete and accurate. I certify that I completed this application myself, without any aid or assistance. If selected, I agree to comply with all regulations of the Carnegie Research Fellowship Program and to return to my home country upon completion of my research program. I understand that my program may be terminated for giving false information, for general misconduct, or for any other reason. I understand that this program excludes accompanying spouse and/or children.


__________________________________________________________________________________________

^ Signature of applicant Date

Privacy policy of the National Council for Eurasian and East European Research (NCEEER) on information concerning candidates and participants in its programs


Information on program candidates and participants is essential to NCEEER in order to carry out its programs and evaluate their quality and effectiveness, as well as for the development of new programs.


NCEEER strictly observes the confidentiality of information obtained from the candidates and participants in its programs and uses this information in accordance with the principles outlined in this document. The principles in this document apply only to NCEEER. Other organizations involved in the administration of these programs may adhere to similar or different policies in working with information on program candidates or participants.


1. Type of information and means of information collection

Information on program candidates and participants consists of the testimony obtained from them in filling out their application forms, the conducting of interviews, and the process of completing the program, as well as data pertaining to program administration. This information, along with contact information, and information on education, professional experience, and work place, may also include personal information.

NCEEER preserves this requested information in both written and electronic forms. Some data—for example, contact information—will be continually updated, in order for representatives of NCEEER to maintain connections with participants, with the goal of sharing information on new programs and projects, and also for the evaluation by participants of program effectiveness.

2. 
   Use of Information
   

Information is used:

• 
  In the evaluation of your candidacy by the selections committee
  
• 
  For presentation to the organizations which finance this program
  
• 
  For presentation to potential participating schools, universities, or other organizations, with the goal of future participation in their academic and professional programs, and also in host families
  
• 
  For the evaluation of the effectiveness of your participation in the program and your compliance with norms and rules outlined by the program
  
• 
  For the timely notification of program graduates of forthcoming meetings and new programs and projects in which they can take part
  
• 
  For data collection in evaluating the effectiveness of the programs being conducted
  
• 
  For conveying to financial establishments and organizations invited by NCEEER to evaluate the effectiveness of the programs being conducted
  
• 
  For conveying to participants and graduates of programs, financed by the United States government, with the goal of creating connections between graduates
  
• 
  For conveying to non-profit organizations with the goal of cooperating in program graduates’ professional development
  

Information about the individuals—candidates and program participants—also may be used by NCEEER, financial organizations, or their representatives, for government statistics and evaluation of program research. The data analyzed in these activities may be published only as part of statistical data. Personal data will not be published. Exceptions are contact information, details relating to academic programs, professional placements (location where the program took place; schools, universities, and other host organizations; discipline; and research theme) and to attract graduates to future post-program activities (participation in meetings for graduates and small grant programs), and also those materials, which participants or program graduates present to NCEEER (provided they are not copyrighted).

By signing this document, you indicate your agreement to the collection, use, storage, and dissemination of information about you in accordance with the conditions laid out above.


______________________________ __________________

Signature Date


___________________________________________


Full Name (printed)


Application Checklist


Have you included:


One original and three copies of:


 Your completed application? (Be sure to keep a copy for your records.)

• 
  Two letters of recommendation (with official stamp)?
  

• 
  Your five to seven page research proposal?
  

• 
  Your curriculum vitae or resume?
  

• 
  A clear photocopy of your international travel passport (if available)?
  

• 
  Privacy Policy Agreement?