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Application For Grant - Kosciuszko Foundation Exchange Program to the U.S. - PAFF & KF Program

Category

I am applying for (Select 1 award category):

Fellowship

Teaching Fellowship

 

Personal Information

Family Name First Name Middle Name
Maiden Name Gender: Male Date of Birth (mm/dd/yyyy)
Female
Place of Birth (City, Country) Citizenship (Please indicate if dual) Valid Until (Leave blank if permanent)

Email Address:

Phone Number:

 

Home Address

Your home address:

Street Address with Apt. #:

City:

State / Province/ Country:

Postal/Zip Code:

 

Employment Address

Institution Name:

Job title (Ex. researcher, professor, student, etc.):

Phone Number (Employer):

Address (Employer):

Street Address with Apt. #:

City:

State / Province/ Country:

Postal/Zip Code:

 

Educational Background

Please list of all institutions completed (university level only, most recent FIRST)

Institution 1:

Field of Study 1:

Degree Received 1:

Date Received/ Expected 1:

Institution 2:

Field of Study 2:

Degree Received 2:

Date Received/ Expected 2:

Institution 3:

Field of Study 3:

Degree Received 3:

Date Received/ Expected 3:

List all professional academic stays in the United States within last 5 years:

List all previous Kosciuszko Foundation and /or Polish American Freedom Foundation Grant(s)/Scholarship(s):

 

Most Recent Publications

List titles of three most recently published books, articles and/or treatises of which you are the principal author ( the most recent FIRST)

Title 1

Publisher 1

Date of Publication 1

Title 2

Publisher 2

Date of Publication 2

Title 3

Publisher 3

Date of Publication 3

 

Research/Study Plans

Please note that the description of your research/studies in the United States is the most important part of the application

A brief summary of your research/studies proposal of no more than two sentences:

The names of the professors or scholars with whom you plan to conduct your research/studies:

The names and addresses of the academic institutions (in order of preference) with which you have made contact:

The MINIMUM length of time you request to complete your research/study:

Do you need the Kosciuszko Foundation's assistance in finding an academic institution(s) in the United States for your research/study?

Yes No
   

Additional Documents

Please list additional documents to this application (Acceptable formats: .doc, .docx, .pdf, .png, .jpg, .jpeg)

 

Your Detailed Typed Research/Study Proposal in English

Must include a well-reasoned argument for conducting your research/study in the United States - max. 500 words ( +/- 10% ONLY):

 

Letters of Reference

Typed in English on OFFICIAL LETTERHEAD. The Kosciuszko Foundation Academic Advisory Committee considers letters of reference to be very important. The letters should be from professors/scholars in the field of your research/studies.

LETTER 1

Name 1:

Title 1:

Institution 1:

Address 1:

Street Address:

Street Address Line 2:

City:

State:

Zip Code:

Country:

LETTER 2

Name 2:

Title 2:

Institution 2:

Address 2:

Street Address:

Street Address Line 2:

City:

State:

Zip Code:

Country:

 

Emergency Contact

Persons to be notified in case of emergency:

Name 1:

Relationship 1:

Phone Number 1: (country code first)

Address 1

Street Address:

Street Address Line 2:

City:

State:

Zip Code:

Country:

Name 2:

Relationship 2:

Phone Number 2: (country code first)

Address 2

Street Address:

Street Address Line 2:

City:

State:

Zip Code:

Country:

 

Persons in the United States to be notified in case of emergency:

Name 1 (US):

Relationship 1:

Phone Number 1:

Address Emergency

Street Address:

Street Address Line 2:

City:

State:

Zip Code:

Name 2 (US):

Relationship 2:

Phone Number 2:

Address Emergency

Street Address:

Street Address Line 2:

City:

State:

Zip Code:


Agreements

By checking the box below, I hereby consent to the processing and transferring of data in the scope necessary for the awarding of scholarships and grants, and the announcing of outcomes of the procedure by the Kosciuszko Foundation Inc., with its seat in New York,      pursuant to the Personal Data Protection Act of August 29,1997 (DZ. U. of 2002, Nr 101 position 926 as amended).

          I agree

By checking the box below, I hereby agree and understand that I am required to have the two recommenders send the letters of reference to the Leaders of Change Foundation at: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра.

         I agree

By checking the box below, I hereby agree to submit a mid-term report and final report. The mid-term report must be submitted by the end of the month that marks the midpoint of your grant/scholarship/fellowship period (max.300 words). The final report must be submitted by the end of the grant/scholarship/fellowship period (max 500 words). Please note you stipend payment(s) may be suspended if the reports not submitted on time. You may also not qualify for any future grant/scholarship/fellowship programs offered by the Kosciuszko Foundation.

         I agree

As a Kosciuszko Foundation Fellow you may receive an opportunity during your grant period to publish papers, articles or books on your research/study, to give public presentations or to participate in broadcast media programs (radio, TV, Internet). In that event, by checking the box below, I agree and understand that I am required to identify myself as a Kosciuszko Foundation Fellow and forward, if possible, copies of your publications, recordings, photos and/or Internet links.

         I agree

PLEASE NOTIFY THE LEADERS OF CHANGE FOUNDATION IMMEDIATELY ABOOUT ANY CHANGES IN YOUR ACADEMIC STATUS OR RESEARCH/STUDY PLANS AFTER THIS APPLICATION HAS BEEN SUMBITTED - CONTACT AT: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра.

Администратор Программы

Фонд «Лидеры преобразований» был создан в феврале 2016 года с целью администрирования, действующих на протяжении многих лет, двух программ Польско-американского фонда свободы: Стипендиальной программы им. Lane Kirkland и Программы Study Tours to Poland. 

ПОЛЬСКО-АМЕРИКАНСКИЙ ФОНД СВОБОДЫ

Польско-Американский Фонд Свободы был основан Польско-Американским Фондом Предпринимательства, который был создан в силу закона «О поддержке демократии в Восточной Европе» (постановление SEED) , принятого в 1989 году конгрессом США.

 

Kirkland logo new 2018 bottom1

Adres

Biuro Programu Stypendialnego im. Lane'a Kirklanda

Fundacja Liderzy Przemian

Al. Jerozolimskie 133 lok. 56

02-304 Warszawa 

fundacja@leadersofchange.pl

PAFW Medium2

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