(Please type or print clearly in black ink.) Name. FAX . Other addresses where you can be located: Date of Birth. # of children and their ages

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1 RUTH CRAWFORD MITCHELL CZECH/SLOVAK SCHOLARSHIP Application for funding to study at the University of Pittsburgh in the Fall Term 20 Completed applications must be received by late March Date of the application (Please type or print clearly in black ink.) Name (family) (first) (middle) (maiden) Address Other addresses where you can be located: Telephone FAX Date of Birth Female Male Marital Status # of children and their ages Place of Birth Education (institutions attended above secondary school) List most recent first. Degrees received or expected Field of Study

2 Fellowships, honors, extra curricular activities, publications (please attach a copy of your CV): Ruth Crawford Mitchell Scholarship Application OCCUPATIONAL EXPERIENCE OVER THE LAST TEN YEARS (List most recent first). FROM Name / Address of Employer TO Position held Name/Address of Employer Dates employed Position held EXPERIENCE OUTSIDE YOUR COUNTRY (Name each country, period of stay, purpose, e.g., study, travel, armed forces, government, etc. It is essential that the applicant specify exact periods of time spent away from his/her own country.) LIST MOST RECENT FIRST. FROM TO Purpose COUNTRY COUNTRY Dates (month/year) Purpose LANGUAGE PROFICIENCY (List the language(s) you speak, especially those related to your study.) Language Excellent Fair Speaking Poor Excellent Reading Fair Poor

3 Ruth Crawford Mitchell Scholarship Application THREE LETTERS, ONE FROM A UNIVERSITY OF PITTSBURGH FACULTY OR STAFF MEMBER, ARE REQUIRED TO COMPLETE YOUR APPLICATION. LIST BELOW THE NAMES OF THOSE WHO WILL WRITE YOUR LETTERS OF REFERENCE. NAME TITLE ADDRESS PHONE In one or two sentences, what is the area and purpose of the study you wish to undertake at the University of Pittsburgh. You will be asked to describe the project more fully on page 5. To what extent have you completed preparatory work on this subject? How do you plan to apply the results gained from this study? What resources do you plan to draw on at the University of Pittsburgh which are not available to you now? List publications you have written which are relevant to your proposed study. (Use a separate sheet of paper, if necessary) DATE TITLE PUBLISHER What are the proposed dates of your stay at the University of Pittsburgh? Arrive in Pittsburgh Leave Pittsburgh FINANCIAL INFORMATION What is your estimate of the entire cost of your proposed study?* Air Fare $

4 Ground Transportation $ Room and Board $ Health Insurance $ Miscellaneous $ TOTAL $ How much of this amount is presently at your disposal? $ Have you applied for or been awarded other funds for this purpose? APPLIED FOR AWARDED Source of funds Amount Source of funds Amount NOTE: No additional transportation, maintenance, or insurance funds are provided for dependents. The scholarship does not include allowances for dependents whether or not they accompany the grantee. Maintenance expenses for dependents are the responsibility of the grantee. Please note that United States government restrictions make employment opportunities for dependents rare. Should an award for an alternate, in the amount of $6,000, become available, do you wish to be considered for it? Yes No *Estimated maintenance is $900 per month (rent $550; food $225); miscellaneous items such as laundry, personal articles, local transportation are additional. Health insurance costs can vary, based on age, between $50 and $100 for the four month period.

5 TWO ESSAYS ARE REQUIRED. PLEASE ATTACH YOUR ESSAYS AS WORD DOCUMENTS AND TO ESSAY 1 Statement of Purpose for Studying at the University of Pittsburgh as the Ruth Crawford Mitchell Scholar State concisely: Current duties in your present employment position Your reasons for wanting to study at the University of Pittsburgh The topic of your research project The research methodology you intend to use Specific faculty, corporate or government officials with whom you would like to work The form the results of your research will take (e.g., journal publication, book, application to governmental or private sector problem What you expect to accomplish in this project which will relate to your overall career goals

6 ESSAY 2 Personal Statement Prepare a narrative describing yourself as an individual. It should deal with your personal history, family background, influences on your intellectual development, the educational and cultural opportunities (or lack of them) to which you have been exposed, and the ways in which these experiences have affected you. Also include your special interests and abilities, career plans, and life goals. Please limit this essay to 500 words in English.

7 AWARDEE OBLIGATIONS THIS STATEMENT IS TO BE SIGNED BY ALL APPLICANTS FOR THE RUTH CRAWFORD MITCHELL CZECH/SLOVAK SCHOLARSHIP, THEREBY AGREEING TO: 1. Make a presentation/lecture to the Czechoslovak Room Committee within one month of arrival in Pittsburgh. 2. Remain at the University of Pittsburgh for the entire Fall Term (approximately 3 1/2 months). 3. Submit a written report on professional accomplishments during your stay to the Director of the Nationality Rooms and Intercultural Exchange Programs before leaving the University of Pittsburgh. 4. Return the full amount of the scholarship if, for any reason, the trip cannot be completed. 5. Return home within three months of completion of study at the University of Pittsburgh. READ CAREFULLY BEFORE SIGNING: I have read and fully understand the above obligations. I agree to be legally bound by them. I shall fulfill all of the commitments if I receive the Ruth Crawford Mitchell Scholarship. Should I, for any reason, be unable to carry out any of these commitments, I shall contact the Nationality Rooms Program office to discuss the resolution of the problem. I understand that if, for any reason, I am unable to make the trip to the University of Pittsburgh, I shall immediately notify the Director of the Nationality Rooms Program, 1209 Cathedral of Learning, University of Pittsburgh, Pittsburgh, PA The telephone number is ; FAX I understand that by clicking on this agreement, I am signing a legal document. I acknowledge that I am the person whose name is listed below on the date listed below. Signature (written) Date Name (printed or typed)

8 Applications must be received by March 30 to be considered for the fall term. Submit by ing the completed PDF file to Cristina Lagnese Incomplete applications will not be processed. Nationality Rooms Program 1209 Cathedral of Learning University of Pittsburgh Pittsburgh, PA Telephone: FAX: