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AMERICAN COUNCILS LOGO

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AMERICAN COUNCILS LOGO

    Application

    Eurasian Regional Language Program

    American Councils for International Education: ACTR/ACCELS

    This application is free of charge and may be duplicated

    Applications should be typewritten if possible;

    otherwise, please PRINT legibly in black ink.

    _____ Spring 2010 _____ Fall 2010

    _____ Summer 2010 _____ Academic Year 2010 2011

1. NAME _________________________________________________________________________________________________ last name first name middle name

    2. INTENDED LANGUAGE OF STUDY ______________________________________________________________________

    3. CITY OF PREFERENCE _________________________________________________________________________________

4. DATE OF BIRTH ____________________________ 5. SEX (circle one) male / female month / day / year

6. PLACE OF BIRTH ____________________________________________________________________________________________________________ city state country

    7. SOCIAL SECURITY NUMBER ________________________ 8. CITIZENSHIP __________________________________

9. PASSPORT NUMBER: ________________________________ 10. EXPIRATION DATE: ___________________________ (passport must be valid for at least eighteen months after your intended arrival in Eurasia) month/ day / year

    IS A COPY OF YOUR PASSPORT, SHOWING NUMBER, SIGNATURE, PHOTOGRAPH, DATE OF BIRTH, AND DATE OF EXPIRATION, ATTACHED TO THIS APPLICATION? _____ yes _____ no

IF NO, WHEN DID YOU APPLY FOR A NEW PASSPORT? _____________

PLEASE NOTE: Your passport must be valid for at least eighteen months after your intended arrival in Eurasia. It can take as long as

    two months to receive a new passport. Your visa will display the same name and passport number as those appearing on the photocopy you submit to American Councils: do not in any way amend your passport, or apply for a new one, after submitting your photocopy to American Councils.

11. E-MAIL ADDRESS: _________________________________________________

12. CURRENT ADDRESS

____________________________________________________________________________________________________________ number and street apartment number

____________________________________________________________________________________________________________ city and state, zip

    American Councils for International Education: ACTR/ACCELS NAME:_________________________________________________________ ACADEMIC AFFILIATION: ____________________________________________

13. CURRENT PHONE: DAY________________________________ EVENING: _____________________________________ area code and phone area code and phone

14. PERMANENT ADDRESS (if different from current)

____________________________________________________________________________________________________________ number and street apartment number

____________________________________________________________________________________________________________city and state, zip

    15. PERMANENT PHONE: DAY ___________________________________ EVENING: _______________________________ area code and phone area code and phone

    16. NAME AND ADDRESS OF PERSON TO CONTACT IN CASE OF EMERGENCY:

____________________________________________________________________________________________________________ name and relationship to you

____________________________________________________________________________________________________________ number and street apartment number

____________________________________________________________________________________________________________ city and state, zip

____________________________________________________________________________________________________________ home area code and phone work area code and phone

___________________________________________ e-mail address

    17. CONTACT INFORMATION OF YOUR STUDY ABROAD OFFICE (if applicable)

___________________________________________________________________________________________________________ name of study abroad director

    ___________________________________________________________________________________________________________ e-mail address

    ___________________________________________________________________________________________________________ office area code and phone

    18. CURRENT ACADEMIC AFFILIATION (if none, leave blank): _________________________________________________

19. EDUCATIONAL BACKGROUND. List all institutions you have attended, beginning with most recent. For “degree/date,”

    enter the month and year of graduation; if you have not yet graduated, put the expected month and year of graduation.

    __________________________________________________________________________________________________________ institution dates of attendance field of study degree/date

    __________________________________________________________________________________________________________ institution dates of attendance field of study degree/date

    __________________________________________________________________________________________________________ institution dates of attendance field of study degree/date

    __________________________________________________________________________________________________________ institution dates of attendance field of study degree/date

    American Councils for International Education: ACTR/ACCELS NAME:_________________________________________________________ ACADEMIC AFFILIATION: ____________________________________________

20. CURRENT ACADEMIC LEVEL: ___ First year undergraduate _____ Graduate Student:

     ___ Sophomore _____ MA Program, _______ - Year

     ___ Junior _____ PhD Program, _______ - Year

     ___ Senior

    If you are a senior, in what month and year will you graduate? __________

    21. EURASIAN LANGUAGE STUDY List all formal or informal study of the language(s) of your host country. Continue on another sheet if necessary.

    ____________________________________________________________________________________________________________ language place of study length of study dates

    ____________________________________________________________________________________________________________ language place of study length of study dates

    ____________________________________________________________________________________________________________ language place of study length of study dates

22. PREVIOUS TRIPS TO OR STUDY ABROAD IN EURASIA:

    ____________________________________________________________________________________________________________ city and country dates of trip

    ____________________________________________________________________________________________________________ city and country dates of trip

    ____________________________________________________________________________________________________________ city and country dates of trip

23. PROFICIENCY IN OTHER LANGUAGES:

    ____________________________________________________________________________________________________________ language place of study length of study dates

    ____________________________________________________________________________________________________________ language place of study length of study dates

    ____________________________________________________________________________________________________________ language place of study length of study dates

24. FINANCIAL AID: Are you applying for financial aid from American Councils? ____ yes ____ no

If yes, a CSS PROFILE form must be filed by the appropriate American Councils deadline.

25. TRANSCRIPTS: Have you requested that transcripts of all college or university level work be sent to American Councils?

_____ yes _____ no

    American Councils for International Education: ACTR/ACCELS NAME:_________________________________________________________ ACADEMIC AFFILIATION: ____________________________________________

    26. PERSONAL REFERENCES. List three persons who have agreed to complete personal reference forms for you. At least one reference should evaluate your proficiency in the language of study. If you have previously studied abroad, your group leader should

    provide a reference

1._________________________________________________________________________________________________________ name

    ___________________________________________________________________________________________________________ address telephone

2._________________________________________________________________________________________________________ name

    ___________________________________________________________________________________________________________ address telephone

3._________________________________________________________________________________________________________ name

    ___________________________________________________________________________________________________________ address telephone

27. FURTHER APPLICATION INFORMATION

    These questions are for research purposes only. They have no bearing on your selection into the program.

    MILITARY SERVICE. Have you ever performed military service or been involved in the armed forces? If yes, please explain:

    __________________________________________________________________________________________________________

LANGUAGE BACKGROUND:

    Are you a native speaker of English? ____ yes ______ no

Are you a native speaker of a language other than English? _____ yes ______ no

    If yes, what language(s)? ______________________________________________________________________________________

Do you speak English at home? _____ yes ______ no

What are your career plans?

    _____A. International relations, foreign service _____G. Research/teaching in Russian related field _____B. Government _____H. Scientific research

    _____C. Business _____I. Health professions, medicine

    _____D. Teaching, other than Eurasian language _____J. Engineering

    _____E. Law _____K. Other: _______________________________

    _____F. Teaching Eurasian language

Are you applying to any other study programs in Eurasia? If so, which ones?

    ____________________________________________________________________________

    American Councils for International Education: ACTR/ACCELS NAME:_________________________________________________________ ACADEMIC AFFILIATION: ____________________________________________

    How did you hear about the American Councils program? Please check one or more of the following:

__ American Councils web page __Your professor __ Program Alum

    __Your study abroad office __ACTR newsletter __AATSEEL Conference

    __CESS Conference __ Listserv Announcement __ Program brochure

    __Email Message __ Other journal________________ __Other (give details below)

    __ASN Conference

Have you applied to any previous American Councils programs? _____ yes _____ no

If so, please indicate for which program you applied and whether or not you participated.

Program: ____________________________________ Period: _______________________________ Participated: ___ yes ___ no

28. CERTIFICATION: Please sign and date below.

I certify by my signature below that all of the information in this application is true and complete to the best of my knowledge.

    Signature _____________________________________________ Date ______________________________

    American Councils for International Education: ACTR/ACCELS

    Eurasian Regional Language Program

    Statement of Purpose

    Name________________________________________ Program: Spring 20____

     last first MI Summer 20___

     Fall 20____

    Academic Year 20___ 20____

     use additional 8 1/2" x 11" sheets as necessary) (do not write on the back of this sheet)

    American Councils for International Education: ACTR/ACCELS

    Eurasian Regional Language Program

    Regional Language Essay

    Name________________________________________ Program: Spring 20____

     last first middle Summer 20___

     Fall 20____

    Academic Year 20___ 20___

     (use additional 8 1/2" x 11" sheets as necessary) (do not write on the back of this sheet)

    American Councils for International Education: ACTR/ACCELS

    Eurasian Regional Language Program

    Financial Aid Application

    Information and Instructions

*If you would like to receive financial aid, it is very important that you follow these directions carefully. It is

    important to submit your financial aid information well before the American Councils application deadline as it takes several weeks for the forms to be processed and received by American Councils. American Councils is not responsible for delayed or incorrect forms. Please consult with your home institution's Study Abroad and Financial Aid offices or the American Councils Russian and Eurasian Programs Office for more information.

    American Councils offers partial scholarships to eligible program participants funded through U.S. Department of State (Title VIII), U.S. Department of Education (Fulbright-Hays), and American Councils. Only U.S. citizens and permanent residents are eligible for these awards. American Councils’ scholarships are based both on merit and need. To determine the financial strength of your family as compared to other families, we ask you to complete the CSS Financial Aid PROFILE form. See the instructions on next page on how to complete a PROFILE form. Be sure to give yourself plenty of time to meet our application deadline for the PROFILE form as it will take CSS approximately 2 weeks for your information to reach American Councils. You should keep copies of the PROFILE for your records. It is not necessary to send American Councils a copy of the form.

    Financial aid is available to both undergraduate and graduate students participating in this program. Graduate Students are eligible for partial fellowships from the US Department of State, Program for Research and Study of Eastern Europe and Eurasia (Title VIII). Undergraduates are eligible for full and partial fellowships from the US Department of Education (Fulbright-Hays). Finally, American Councils also provides limited financial aid to outstanding students with demonstrated financial need.

    If you are a graduate student and wish to apply for financial aid through the Department of State, you should: ; Check "yes" on question 24.

    ; Complete the American Councils Financial Aid form (attached)

    ; Complete a CSS Profile form on line (instructions on next page)

    ; Address in your statement of purpose ways in which your future studies and/or career will benefit US

    national interests by enabling US policy makers to better understand Eurasia. Please note: American

    Councils encourages applications for Title VIII support from graduate students in all fields of the

    humanities, languages and social sciences.

    If you are an undergraduate and wish to apply for Financial Aid through the Department of Education, you should:

    ; Check "yes" on question 24.

    ; Complete the American Councils Financial Aid form (attached)

    ; Complete a CSS Profile form on line (instructions on next page)

    ; In your statement of purpose, describe your interest in teaching and/or the education field.

If you wish to apply for American Councils financial aid, you should:

    ; Check "yes" on question 24.

    ; Complete the American Councils Financial Aid form (attached)

    ; Complete a CSS Profile form on line (instructions on next page)

    American Councils for International Education: ACTR/ACCELS

    Eurasian Regional Language Program

    Financial Aid Application

    Information and Instructions (Continued)

The CSS Financial Aid PROFILE registration form can be obtained:

     a) via the internet on the World Wide Web: www.collegeboard.org

     b) by phone: 1-800-778-6888 (for those living outside the U.S., Canada, or Puerto Rico,

    call 1-305-626-4729)

     c) at your home institution's Financial Aid office

     **When filling out this form, for item #15, enter American Councils' code number: "2707".

You can now complete your PROFILE online at www.collegeboard.com. This is the fastest method for

    reporting.

    NOTE: ACTR cannot award ANY financial aid without receiving your PROFILE report from the CSS.

Other possible sources of funding include:

    ; The National Security Education Project has funded many participants in the past. For more information,

    visit the websites http://nsep.aed.org/ (graduate students) and www.iie.org/nsep (undergraduate students).

    ; Many colleges and universities also provide financial aid for participation in American Councils programs.

    ; The Benjamin A. Gilman International Scholarship may be applicable to this program. The online

    application is now available at the Gilman Program website: www.iie.org/gilman.

    American Councils for International Education: ACTR/ACCELS

    Eurasian Regional Language Program

    Financial Aid Application

     o Summer 20____ o Fall 20____ o Spring 20____ o Academic Year 20____ - ____

    Name ___________________________________ Academic Affiliation ______________________________________

    Please check the appropriate space: _____ undergraduate _____ graduate _____ not currently enrolled

    Expected Date of Graduation: ___________________________________________ (please indicate month and year)

What forms of financial aid, if any, have you received for your undergraduate and graduate education to date? Please specify the

    amount from each source:

    Type of awardUndergraduateGraduate

List the total amount of your assets in cash, savings, and checking accounts: $____________________ scholarship/fellowship

    Taxable income: (past year) $____________________ (current year) $____________________

    Total accumulated debt: (educational loans) $___________________ (other debt) $____________________

What are the economy round trip transportation costs between your point of departure and Washington, D.C. (site of the pre-departure

    orientation)? $____________________ loan (specify type)

From what sources other than American Councils do you expect to receive funding? Please list total for each source indicated. (Use a

    separate sheet if necessary.) ___________________________________________________________________________________

Keeping in mind that American Councils has partial scholarships only to help offset program costs, what amount of financial aid are

    you requesting from American Councils? $_________________________(please give a dollar amount) other(specify type)

    Do you authorize the Financial Aid Committee to consult with your FA officer concerning this application? _____ yes _____no

    Have you completed an application for a CSS PROFILE report using the information above? _____ yes _____no

    If no and you are requesting need-based financial aid, please do so. If yes, when? _________________________

    *Please note: American Councils must receive the original Financial Need Analysis Reports directly from CSS.

I certify by my signature that the above information is correct and complete.

    Signature _________________________________________________________ Date ___________________________

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