U.S. Office of Palestinian
Affairs

SUSI 2024- Nomination Form

Nomination Form

Application Deadline: No later than December 29, 2023

Please complete and send to below emails attaching your updated resume and copy of your passport biographical information Jerusalemexchanges@state.gov (Jerusalem, West Bank) / JerusalemGazaExchanges@state.gov (Gaza)

SUSI program you are applying for:

A. Nominee’s Full Name: Last Name(s), First Name, Middle Name.

B. Gender

C. Date of Birth (please spell out Month, Day, Year)

D. Birth City

E. Birth Country

F. Country(ies) of Citizenship:

G. Country of Residence

H. Medical, Physical, Dietary or other Personal Considerations:

I. Candidate Contact Information: Home Address, City, E-mail, and Telephone.

J. Current Position/Title, Institutional Name, and Country

K. Work Experience, including previous positions and titles, place

L. Education: Academic & Professional Training, degree earned and fields of specialization, place.

M. Active Professional Memberships

N. Publications: publication year, type of publication, title, and publisher.  All foreign titles should be translated into English. (Please list no more than 10.)

O.  Previous Experience in the United States: trips made to the United States; dates & reason.

P. Family Residing in the United States:

Q. Evidence of English Fluency (e.g. personal interview, test score, etc.)

R. Personal Statement of Interest (no more than one page):