Complete This Form in English Except Where Otherwise Indicated. the Form Should Be Typewritten

PRELIMINARY APPLICATION FOR 2016 HUBERT H. HUMPHREY FELLOWSHIP PROGRAM UNDER THE FULBRIGHT PROGRAM

Complete this form in English except where otherwise indicated. The form should be typewritten in black ink or printed from a computer. Submit the completed application along with required supporting documents to the Thailand-U.S. Educational Foundation (Fulbright) within the application deadline.

Attach a photograph ************ taken within the 1. Name (underline family name): past year (make Mr., Ms., Mrs. (English) …………………………………...... ….…...... sure your full name is written on the (Thai) …………………………………………………………….….…... back). Proposed Major Field of Study: ...... …….….... Specific Area of Major Field: ...... …….…….…. ______2. Mailing Addresses: a. Home: (English)...... ………...... ……………………………………… Tel. ..………………………...…....Mobile Phone No….………………………...... (Thai) ...... …………………… .…………...... b. Office: (English) ...... ……………...... ……………………...... ………………..…. Tel. …....………………...... Fax: …………………………. E-mail: ………………………………………..…. ______3. Are you a government official? Yes ..... No .... If yes, please indicate date of permanent employment: ...... 4. Personal Data: Age ....…. Date of Birth ...... …...... Place of Birth …...... Citizenship ...... …...... Marital Status: Single ...... …. Married ...…...... Divorced ...…...... Widowed .……...... Name of Spouse: (Thai) ...... …………...... …………...... … Occupation and Address of Spouse: ...... ………...... …..……. Tel...... ………………………... 5. Education: List all post-secondary educational institutions attended, beginning with the most recent, including any in which you are currently enrolled.

Institution/University Major field(s) of Dates attended Name of Date received study (mo & yr) diploma or or expected From To degree 1. 2. 3. 4.

1 6. Occupational Experience: (Give present position first, then next most recent positions) Position Firm/Organization Type of Major Work Dates (Mo.& Yr.) From To ...... …...... …...... ………...... …...... ….…... ……..…… present ...... …...... …...... ………...... …...... …...... ….…...... …..… ……..…...... …...... …...... ………...... …...... …...... …..…...... ….… ……..…...... …...... …...... … ...... ………...... …...... …...... ……...... ……… ……..…...... …...... …...... ………...... …...... …...... …… ...... …... ……..….. Total ...... years of working experience (excluding the periods of study)

If you are awarded a scholarship, do you have a guarantee of employment upon your return home? Yes ….…. No…..…. ______7. Describe your current job responsibilities: ...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…. 8. Give a 50-word summary of your proposed program plan ...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…. 9. What do you plan to do upon your return to Thailand? ...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…...... ……………………...... ………………..…. 10. References: Name Position Address a...... …...... …...... …...... …...... ……...... …………...... … b...... …..…...... ….. …...... …...... ………...... ………......

11. Please indicate countries outside your own, including the United States, in which you have lived, traveled, or studied. Please list dates (months/years) and reasons for each visit.

Country/Town visited Reason for visit From (mo/yr) To (mo/yr) 1. 2. 3. 4. 5. 6.

12. Proposed Program Plan: 2 (a) Please describe your major area of interest and explain how this area addresses the specific development needs of your country.

(b) Describe the type of Humphrey program you would like to design in order to meet these challenges. Indicate the kinds of academic course work, internship experiences, and/or professional training experiences you would like to undertake.

(c) Describe how the acquisition of new knowledge and skills will assist you in helping your country to achieve its development goals.

3 13. Personal Statements A: Write a paragraph answering each of the following questions. (a) Please describe how you have demonstrated a strong commitment to public service. (i.e. community, civic involvement or professional responsibilities, etc.)

(b) Please state your professional goals for the next five years and indicate how the training received under the Humphrey Program will contribute to your managerial skills, leadership ability, and commitment to public service.

14. Personal Statements B:

Describe a problem or challenging situation that you have resolved by using your initiative. What was the outcome? Please select this example carefully. It should illustrate something that you want the review panel to know about your problem-solving, leadership abilities, or commitment to public service. The essay should not exceed this page.

I certify that the information provided in this application is complete and accurate to the best of my knowledge. I have read the program announcement. I agree to abide by the provisions, requirements and selection process of the program. I understand that unclear and incomplete applications will not be considered by the Binational Selection Committee. I also acknowledge that grantees who required more than one year to complete the master’s degree are expected to find support from other sources for their study program in the United States beyond the initial year. Renewal of the grants will be considered on a case by case.

…….……….………….…………………. …….……..………………………..……………………… …………………………… Signature Print or Type Name Date

5 Rev. 04/2015