1. Print Form Submit by Email
"E-TEACHER" SCHOLARSHIP PROGRAM -
ENGLISH TEACHING DISTANCE LEARNING PROGRAM: APPLICATION 2013
Please email this application to:
Regional English Language Office, Public Affairs Section, U.S. Embassy Islamabad, at
PakistanRELO@state.gov.
OR fax it at +92.51.227.8040 (attn.: Abdul Majeed) by January 25th, 2013.
1. NAME OF APPLICANT:
a. Family name. T
b. First name.
c. Middle name. T
T
d. Prefix (Mr./Ms./Mrs.). T
2. PERMANENT ADDRESS OF APPLICANT:.
a. Street and Apt. no.:.
b. City, Postal Code:.
T
c. Home Phone number:. (include city code).
T
d. Work Phone number:. (include city code).
e. Cell Phone number
T
f. Fax: (include city code).
T
g. E-mail address:
T
3. SEX
T
: (male/female).
4. PLACE OF BIRTH.
T
(city and country):. T
5. DATE OF BIRTH.
(DAY/MONTH/YEAR):
T
6. CURRENT OCCUPATION:
T
a. Your job title.
b. Dates of Employment (month and year).
T
c. Name and address of your place of employment.
T
T

2. 7. Please indicate countries outside your own, including the United States, in which you
have lived, traveled, or studied. Please list dates (months/years) and reasons for each visit.
Country visited. T
Reason for visit:
(e.g. study, work, tourism, conference) e
please be specific.
T
Dates of visit: T
From. (Mo./Yr.) T To (Mo./Yr.) T
8. Please enclose your ONE-PAGE brief curriculum vitae (CV).
9. How did you hear about us?
T
10. Please choose the course you would like to take (A, B, C, D, E, F, G, H, I ):
A. Introduction to Online Learning (Online Learning 5-weeks)
B. Practical Applications in Listening and Speaking Skills (PALSS)
C. Introduction to Pedagogy and Practices for Teaching English to Speakers of Other
Languages (TESOL Methods)
D. Critical Thinking in Language Learning and Teaching (CT)
E. Building Teaching Skills through the Interactive Web (Web Skills)
F. Assessment: Summative and Formative Practices in Language Learning and Teaching
(Assessment)
G. English for Specific Purposes, Best Practices for Courses and Materials (ESP)
H. Special Education and Differentiated Instruction in an EFL Context (SpEd TEFL)
I. Teaching English to Young Learners (TEYL)

3. 11. Please outline your interest in taking the course chosen in 10.
T
e
x
t
F
i
12. Please assess your present English language proficiency (excellent, good or fair)..
a. Understanding written English.
b. Expressing thoughts in written English
T
T
13. Do you have a round the clock internet connectivity?
14. If you answered "yes" to the question 13, how much time do you spend online every
T
day?
15. Which internet browser do you use:
T
16. Which Operating System do you use:
T
17. Please provide a referee who could comment on your work and English language
T
proficiency.
REFEREE
a. Last name. T
b. First name. T
c. Middle name.T
d. Job title.
e. Place of employment (include city). T
T
f. Email address.T
g. Phone number (include city code). T