I am applying for (Select 1 award category):
❍ Fellowship
❍ Grant
First Name
Gender
❍
❍ Teaching Fellowship
Middle Name
Date of Birth (mm/dd/yyyy)
Male
Family Name
Maiden Name
Place of Birth (City,
Country)
❍ Female
Citizenship (Please indicate if dual)
Address (Include house number)
(HOME)
Email Address
City
Postal Code
Valid Until (Leave blank if permanent)
Institution Name
Job Title (Ex: Researcher, professor, student,
etc..)
Address (EMPLOY)
City
Postal Code
Telephone
Telephone (Include country
code)
Fax #
Institution 1
Field of Study 1
Degree Received 1
Date Received/ Expected 1
Institution 2
Field of Study 2
Degree Received 2
Date Received 2
Institution 3
Field of Study 3
Degree Received 3
Date Received 3
List all professional academic stays in the United States within last 5 years:
List all previous Kosciuszko Foundation Grant(s)/Fellowship(s):
Title 1
Publisher 1
Date of Publication 1
Title 2
Publisher 2
Date of Publication 2
Title 3
Publisher 3
Date of Publication 3
A brief summary of your research/studies proposal of no more than two sentences.
The names and addresses of the academic institutions (in order of preference) with which you made contact. Include the title
or position of the individual who accepted you.
The names of the professors or scholars with whom you plan to conduct your research/studies.
The estimated MINIMUM length of time you believe necessary to complete your research/study.
Name 1
Title 1
Institution 1
Address 1
Name 2
Title 2
Institution 2
Address 2
Name 3
Title 3
Institution 3
Address 3
Name 1 (POL)
Address (Include house
number) 1
Relationship 1
Phone (Include country
code) 1 (
Name 2 (POL)
Address (Include house
number) 2
Name 1 (US)
Address (Include house
number) 1
Name 2 (US)
Address (Include house
number) 2
Relationship 2
Phone (Include country
code) 2
Relationship 1
Phone 1
Relationship 2
Phone 2
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).
❏
By checking the box below, I agree and understand that I am required to have three recommenders send letters of reference
to: [email protected].
❏
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