Please return the completed format to relomexico@state.gov
by Sunday, June 29, 2014
Instructions:
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Download the application form to your computer. Save it to your hard disk as a .doc file (Windows 97-2003) with
your two last names as the file name. Example: gonzalezarroyo.doc Do not save the document as a .docx
(Windows 2007-2010) or .odf/.odt (Open Office) file because it will not work properly!
It’s advisable to read the format carefully before filling it out because there are changes from previous years. Make
sure to include all of the information labeled “mandatory”.
To start filling out the format, use the TAB key.
The format will only allow you to type in the shaded areas.
To move from one box to the next, use the TAB key or the → ↑ arrow keys. To move back, press SHIFT (mayúsculas)
and TAB at the same time or use the ← ↓ arrow keys.
To check a box, click on it or type X. To uncheck it, click on it again or type X again.
Should you have any questions or need help to fill out this form, please contact José Manuel Villafuerte – 01-555080-2000, ext. 5269, or Brenda Bernáldez – ext. 5270.
What e-teacher course are you applying for? (mandatory)
You may choose up to three options. Please use 1 for your top choice, 2 for your second option and 3
for your least favorite.
Disclaimer: Because of high demand and limited supply, we cannot guarantee that your application will actually
result in a scholarship or that you will receive a scholarship for your top choice. Preference will be given to those
who have not received a scholarship before and to E-Teacher graduates who have submitted evidence of having
shared what they learned.
Building Teaching Skills through the Interactive Web
Introduction to Pedagogy and Practices for Teaching English to Speakers of Other Languages
Practical Applications in Language and Learning Skills (only offered in Winter term, Jan.-Mar. 2015)
English for Specific Purposes: Aligning Context with Practices and Materials
Special Education and Differentiated Instruction in EFL Contexts
Teaching English to Pre-Teens and Teens
Teaching English to Young Learners between 5 and 12 years old (TEYL)
Summative and Formative Assessment in Language Learning and Teaching
Critical Thinking in Language Learning and Teaching
Developing Local Leadership for Global English Language Teaching (This course is designed for
coordinators or directors that manage students/schools. It is not for classroom teachers.)
Personal Data: (mandatory)
Last name(s):
Given name(s):
Nationality/Nationalities:
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Contact information: (mandatory)
Preferred mailing address (street, number, and apartment number):
Colonia:
Postal code:
City:
State:
Work telephone number (provide area code and extension):
01 (
)
Home telephone number (provide area code):
01 (
)
Cell/Mobile phone:
044
e-mail 1:
ext.
Confirm e-mail 1:
e-mail 2 (optional):
Confirm e-mail 2:
Candidate profile: (mandatory)
Which of the following best describes what you do? Check all that apply.
I work
at a public institution
as a freelance teacher
I teach
Other. Please explain:
preschool/ages 4-5
prepa level/ages 16-18
at a private institution or language institute
primaria/ages 6-12
secundaria/ages 13-15
university level/ages 19 and above
adults/ages 25 and above
I teach/train pre-service English teachers at a university or Normal school
I train in-service English teachers
I do research in language teaching
I supervise teachers (I am a coordinator, director, etc.) How many teachers do you supervise?
Other. Please explain:
Current position: (mandatory)
Please specify name of institution and starting date.
Dates
Position and Institutional Affiliation
From
to date
Position/Title:
Institution:
Responsibilities:
Concurrent positions: (if applicable)
From
Dates
to date
Position and Institutional Affiliation
Position/Title:
Institution:
Previous positions:
Provide dates starting with most recent and working your way back. Do not list your current job.
Dates
Position and Institutional Affiliation
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From
to
From
to
From
to
From
to
From
to
Position/Title:
Institution:
Position/Title:
Institution:
Position/Title:
Institution:
Position/Title:
Institution:
Position/Title:
Institution:
Publications or academic presentations:
Provide the three most recent ones only.
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For publications, provide the complete bibliography (author, year, title, publisher/periodical, etc.).
For presentations, mention year, title, type of presentation (workshop, paper, etc.), and name of the
event.
1.
2.
3.
Memberships:
1.
2.
3.
Educational background: (mandatory)
Only list university level studies and above, as well as diplomados and especializaciones. Start with the
most recent and work back. Include dates, degree, area of specialization, and academic institution.
Please list degrees in the language you received them: Licenciatura, Maestría, etc. Example: Licenciatura
en Letras Modernas (Inglesas).
Dates
Degree, area of specialization
Academic institution
From
to
From
to
From
to
From
to
Continued on next page.
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How do you plan to share what you learn?
Briefly explain what actions you will take to share what you learn if you receive a scholarship. These may
include, but not be limited to, advising, counseling, mentoring, workshops, presentations, articles, etc.
Statement of purpose (mandatory)
2,000 CHARACTERS MAXIMUM. Every letter, punctuation mark and space counts as a character.
In about half a page state why you are interested in participating in the E-Teacher program as clearly and succinctly as
possible. Explain what impact your participation in this program would have on your institution/region, and how you
expect to put to good use and share, in the short term, the knowledge acquired in this course.
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