Name:_________________________________ Social Security #______________________________
Address:_______________________________ Home Phone:________________________________
Male __________ Female___________ Smoking____________ Non-smoking_____________
City__________________________________ Country__________________ Zip________________
Name of School and Phone:____________________________________________________________
E-Mail:_____________________________________________________________(please print legibly!)
Fax Number:_________________________________________________________________________
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The information below must be completed without leaving any blanks!
NASA Required Information
Are you a Permanent Resident Alien (Greencard Holder): YES____ NO____
If YES, Number: ______________ Date Issued: __________________ Expiration Date:______________
Nationality: _________________ Date of Birth: ____________
City of Birth: ___________________ Country of Birth:_________________
Permanent Home Address: ________________________ ____________________________________
Affiliation or Employer:
Institution or Company Name: ___________________________________________________________
Address:____________________________________________________________________________
Title or Position and Duties: ___________________________ Phone Number: _______________
U.S. Visa Information:
U. S. Visa Number: ___________ U. S. Visa Type (e.g.; B-1/B-2, H-1B, J-1, F-1, etc):__________
U. S. Visa Expiration Date: __________________________
If J-1, name of U.S. Program Sponsor (attach IAP-66 or DS2019): _______________________________
Passport Information:
Passport Number: ______________________ Passport Expiration Date: ________________________
Country of Issue: ____________________________ Date of Issue: _____________________________
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Current Teaching Experience:
____________________________________________________________________________________
Location Years Grade Level/Subjects
EDUCATION: BA/BS (circle one)
____________________________________________________________________________________
University Major Year
Credential(s): ________________________________________________________________________
EDUCATION: Masters Degree yes/ no (circle one)
____________________________________________________________________________________
University Major Year
Additional Course Work: ___________________________________________________________
__________________________________________________________________________________
Briefly state your reasons for applying for this Institute and how you feel it will benefit your school
and you as a teacher. Use space below. If necessary continue on back of form. DO NOT use additional pages. ___________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
If I am selected I will attend all scheduled sessions including the opening dinner and complete all academic assignments.
Teacher's Signature_____________________________________Date______________
Chief School Administrator Endorsement ______________________________Date_____________
Return the completed form to the Office of Overseas Schools, U.S. Department of State,
H328, SA-1, Washington, D.C. 20522-0132 by Friday, February 22, 2008.
ATTN: Dr. Beatrice Cameron (A/OPS/OS) Fax Number: 202-261-8224
