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Global Mission<br />
International Lea<strong>de</strong>rship Development Program<br />
INTERNATIONAL SCHOLARSHIP APPLICATION FORM CHECKLIST<br />
The Evangelical Lutheran Church in America (<strong>ELCA</strong>), through its Global Mission unit (GM), offers a limited number of scholarships to<br />
companion churches and institutions. The goal is to accompany these churches and institutions in their various lea<strong>de</strong>rship <strong>de</strong>velopment<br />
needs. The scholarship is inten<strong>de</strong>d for the church or institution and not as a personal scholarship.<br />
Please respond to all questions, even if the answer is “none” or “not applicable.” If possible, please complete online and submit electronically;<br />
otherwise print legibly. The application is to be completed in English (preferable), French or Spanish.<br />
A complete scholarship application will inclu<strong>de</strong> the following:<br />
□□<br />
The core application form (International Scholarship Application Form) — to be completed by the applicant.<br />
□□<br />
Teacher Form (Confi<strong>de</strong>ntial Letter of Recommendation) — to be completed by two different present or former teachers.<br />
□□<br />
Personal Form (Confi<strong>de</strong>ntial Letter of Recommendation) — to be completed by two different individuals (not relatives) who have<br />
known the applicant for at least three years.<br />
□ Institutional Endorsement Form — to be completed if the applicant is being endorsed by a source other than, or in addition to, a<br />
companion church. This form is to be completed by the authorized official of the institution or agency.<br />
□ Church Endorsement Form — to be completed by an authorized official of the <strong>ELCA</strong> companion church.<br />
□ Certificate of Health Form — to be completed by a medical doctor in conjunction with a physical examination.<br />
□ Narrative of Self, Faith Statement and Goals.<br />
□ Estimated Budget Worksheet or copy of official school budget — school fees and living expenses if applicable (If not attending<br />
an <strong>ELCA</strong> institution.)<br />
□ Acceptance Letter from educational institution you plan to attend (If not attending an <strong>ELCA</strong> institution.)<br />
□ The Description of Proposed Study Program, Aims and Goals (page 9) is to be completed in <strong>de</strong>tail.<br />
Please inclu<strong>de</strong> physical copies of:<br />
□□<br />
If aca<strong>de</strong>mic study is inten<strong>de</strong>d in an English-medium setting, the Test of English as a Foreign Language (TOEFL) is required. Educational<br />
institutions in the United States of America will not consi<strong>de</strong>r an application from a potential international candidate<br />
without a current TOEFL score. If you do not take the TOEFL, you must take the Graduate Record Examination (GRE – graduate<br />
studies) or the Scholastic Aptitu<strong>de</strong> Test (SAT – for un<strong>de</strong>rgraduate studies). If you have taken the TOEFL test within the last two<br />
years, you must inclu<strong>de</strong> a copy of your TOEFL score with your scholarship application. If you have not already taken the TOEFL<br />
test, do so immediately and have the results sent to the <strong>ELCA</strong>/GM office. Please use the TOEFL institutional co<strong>de</strong> 9295. The<br />
International English Language Testing System (IELTS) is an appropriate alternative.<br />
□□<br />
Please have Official Aca<strong>de</strong>mic Transcripts from educational institutions where you have studied forwar<strong>de</strong>d to the Director for<br />
International Lea<strong>de</strong>rship Development at the address listed below.<br />
applicant information: please fill out via pdf or print legibly<br />
Name<br />
last name (as appears on passport/birth certificate/etc.)<br />
first name/given name (as appears on passport/birth certificate/etc.)<br />
other name(s)<br />
title (rev/dr/ mr/mrs/ms/other - please specify)<br />
National Church Membership<br />
8765 West Higgins Road ● Chicago, Illinois 60631-4101 ● Phone 773-380-2700 Fax 773-380-2410 ● www.elca.org<br />
GM_ISA_04162013_v001 1
INTERNATIONAL SCHOLARSHIP APPLICATION FORM<br />
Global Mission<br />
International Lea<strong>de</strong>rship Development Program<br />
NOTE: Application <strong>de</strong>adline is October 15 of each year for programs that begin after February 1 the following year.<br />
1 personal information<br />
Name<br />
last name (as appears on passport/birth certificate/etc.)<br />
first name/given name (as appears on passport/birth certificate/etc.)<br />
other name(s)<br />
title (rev/dr/mr/mrs/ms/other - please specify)<br />
Birth Date Country of Citizenship Country of Resi<strong>de</strong>nce<br />
mm/dd/yyyy<br />
Mailing Address<br />
Permanent Address (If different from mailing address)<br />
street address (apartment resi<strong>de</strong>nts - inclu<strong>de</strong> unit number here as well)<br />
street address (apartment resi<strong>de</strong>nts - inclu<strong>de</strong> unit number here as well)<br />
city/town state/province postal co<strong>de</strong><br />
city/town state/province postal co<strong>de</strong><br />
Email<br />
country<br />
country<br />
Cellphone (Mobile)<br />
Passport Number<br />
Issued By<br />
country<br />
Dates of Validity<br />
mm/dd/yyyy - mm/dd/yyyy<br />
2 emergency contact information<br />
Name<br />
Address<br />
street address city/town state/province postal co<strong>de</strong> country<br />
Relationship<br />
Phone<br />
Email<br />
3 standardized test information<br />
Check one:<br />
□□<br />
TOEFL<br />
□□<br />
GRE<br />
□□<br />
SAT<br />
□□<br />
IELTS<br />
Score<br />
or Scheduled Test Date<br />
mm/dd/yyyy<br />
For study in English language settings, please provi<strong>de</strong> a copy of the results.<br />
8765 West Higgins Road ● Chicago, Illinois 60631-4101 ● Phone 773-380-2700 Fax 773-380-2410 ● www.elca.org<br />
GM_ISA_04162013_v001 2
4 church affiliation information<br />
National Church Membership<br />
Congregational/Parish Membership<br />
Date of Baptism<br />
mm/dd/yyyy<br />
If clergy, date of ordination<br />
mm/dd/yyyy<br />
5 family information<br />
Marital Status (Please check one)<br />
Full Name of Spouse<br />
□□<br />
Married<br />
□□<br />
Single<br />
last name (as appears on passport/birth certificate/etc.)<br />
first name/given name (as appears on passport/birth certificate/etc.)<br />
other name(s)<br />
title (rev/dr/mr/mrs/ms/other - please specify)<br />
Birth Date<br />
Birth Place<br />
mm/dd/yyyy<br />
town/province/ district/ country<br />
Country of Citizenship<br />
Country of Resi<strong>de</strong>nce<br />
Can your spouse read or speak English?<br />
Read (check one):<br />
□□<br />
Yes<br />
□□<br />
No<br />
Speak (check one):<br />
□□<br />
Yes<br />
□□<br />
No<br />
Children<br />
1. Name<br />
Gen<strong>de</strong>r:<br />
□□<br />
Male<br />
□□<br />
Female<br />
Birth Date<br />
mm/dd/yyyy<br />
Citizenship<br />
country<br />
2. Name<br />
Gen<strong>de</strong>r:<br />
□□<br />
Male<br />
□□<br />
Female<br />
Birth Date<br />
mm/dd/yyyy<br />
Citizenship<br />
country<br />
3. Name<br />
Gen<strong>de</strong>r:<br />
□□<br />
Male<br />
□□<br />
Female<br />
Birth Date<br />
mm/dd/yyyy<br />
Citizenship<br />
country<br />
4. Name<br />
Gen<strong>de</strong>r:<br />
□□<br />
Male<br />
□□<br />
Female<br />
Birth Date<br />
mm/dd/yyyy<br />
Citizenship<br />
country<br />
FOR THOSE SEEKING STUDY IN THE UNITED STATES<br />
Do you have any family members presently living in the United States of America? (check one)<br />
(family members: spouse/children/parents/brothers/sisters/grandparents/aunts/uncles/cousins)<br />
□□<br />
Yes<br />
□□<br />
No<br />
Please list all relatives living in the United States of America:<br />
1. Name<br />
Phone Number<br />
Address<br />
Relationship<br />
street address city/town state/province postal co<strong>de</strong><br />
Number of years in the U.S.A.<br />
GM_ISA_04162013_v001<br />
3
5 family information (continued)<br />
2. Name<br />
Phone Number<br />
Address<br />
Relationship<br />
street address city/town state/province postal co<strong>de</strong><br />
Number of years in the U.S.A.<br />
3. Name<br />
Phone Number<br />
Address<br />
Relationship<br />
street address city/town state/province postal co<strong>de</strong><br />
Number of years in the U.S.A.<br />
6 aca<strong>de</strong>mic information<br />
(including past and present)<br />
Secondary/High School<br />
Name<br />
Address<br />
street address city/town state/province postal co<strong>de</strong> country<br />
Entrance Date<br />
mm/yyyy<br />
Graduation/Departure Date<br />
mm/yyyy<br />
Degrees Received or Credits Earned<br />
Field of Specialization (if any)<br />
College/University/Seminary<br />
Name<br />
Address<br />
street address city/town state/province postal co<strong>de</strong> country<br />
Entrance Date<br />
mm/yyyy<br />
Graduation/Departure Date<br />
mm/yyyy<br />
Degrees Received or Credits Earned<br />
Field of Specialization (if any)<br />
College/University/ Seminary<br />
Name<br />
Address<br />
street address city/town state/province postal co<strong>de</strong> country<br />
Entrance Date<br />
mm/yyyy<br />
Graduation/Departure Date<br />
mm/yyyy<br />
Degrees Received or Credits Earned<br />
Field of Specialization (if any)<br />
GM_ISA_04162013_v001<br />
4
6 aca<strong>de</strong>mic information (continued)<br />
Post Graduate/Other/Special<br />
Name<br />
Address<br />
street address city/town state/province postal co<strong>de</strong> country<br />
Entrance Date<br />
mm/yyyy<br />
Graduation/Departure Date<br />
mm/yyyy<br />
Degrees Received or Credits Earned<br />
Field of Specialization (if any)<br />
Other Experience or Training<br />
International Travel or Study Experience (please explain)<br />
7 language proficiency - ancient or mo<strong>de</strong>rn<br />
Languages<br />
Speak:<br />
Speak:<br />
Speak:<br />
Speak:<br />
□□Fluent<br />
□□Fluent<br />
□□Fluent<br />
□□Fluent<br />
□□Conversational<br />
□□Conversational<br />
□□Conversational<br />
□□Conversational<br />
Read:<br />
Read:<br />
Read:<br />
Read:<br />
□□Yes<br />
□□Yes<br />
□□Yes<br />
□□Yes<br />
□□No<br />
□□No<br />
□□No<br />
□□No<br />
Write:<br />
Write:<br />
Write:<br />
Write:<br />
□□Yes<br />
□□Yes<br />
□□Yes<br />
□□Yes<br />
□□No<br />
□□No<br />
□□No<br />
□□No<br />
For those seeking study in English-medium countries, have you taken any courses or participated in any activities where<br />
English was the primary language? (If yes, when and where?) □□Yes<br />
□□No<br />
8 work history<br />
(begin with current or most recent position)<br />
1. Dates of Employment<br />
Organization/Employer<br />
mm/yyyy -mm/yyyy<br />
Title/Position<br />
Type of Work<br />
2. Dates of Employment<br />
Organization/Employer<br />
mm/yyyy -mm/yyyy<br />
Title/Position<br />
Type of Work<br />
GM_ISA_04162013_v001<br />
5
8 work history (continued)<br />
3. Dates of Employment<br />
Organization/Employer<br />
mm/yyyy -mm/yyyy<br />
Title/Position<br />
Type of Work<br />
4. Dates of Employment<br />
Organization/Employer<br />
mm/yyyy -mm/yyyy<br />
Title/Position<br />
Type of Work<br />
9 financial information<br />
How much money can you contribute to the cost of your education?<br />
If you have a family, what provisions will be ma<strong>de</strong> for the support of your spouse and children during your absence?<br />
10 medical information<br />
Are you or any member of your family un<strong>de</strong>r treatment or observation for any illness or injury?<br />
□□<br />
Yes<br />
□□<br />
No<br />
If yes, please give <strong>de</strong>tails:<br />
GM_ISA_04162013_v001<br />
6
CONFIDENTIALITY AGREEMENT<br />
Global Mission<br />
International Lea<strong>de</strong>rship Development Program<br />
Please initial appropriate option below. We recommend that you initial option one. Doing so enables us to carry out our<br />
selection process more effectively.<br />
Option One<br />
I waive all rights to read any letters of reference (two Teacher<br />
Confi<strong>de</strong>ntial Letters of Recommendation and two Personal<br />
Confi<strong>de</strong>ntial Letters of Recommendation) submitted with this<br />
application, as provi<strong>de</strong>d for in the United States of America<br />
Family Educational Rights and Privacy Act of 1974.<br />
Option Two<br />
I do NOT waive rights of access.<br />
Applicant’s Signature<br />
Date<br />
mm/dd/yyyy<br />
PLEASE UPLOAD A PHOTOGRAPH VIA EMAIL<br />
appendices<br />
DESCRIPTION OF PROGRAM (pages 9-10 )<br />
PERSONAL NARRATIVE, FAITH STATEMENT AND GOALS (page 11)<br />
PERSONAL COMMITMENT AGREEMENT (page 13)<br />
TEACHER RECOMMENDATION FORMS (pages 15-18 - two copies)<br />
PERSONAL RECOMMENDATION FORMS (pages 19 - 22 - two copies)<br />
INSTITUTIONAL ENDORSEMENT FORM (page 23)<br />
and/or CHURCH ENDORSEMENT FORM (page 25)<br />
CERTIFICATE OF HEALTH FORM (page 27)<br />
ESTIMATED BUDGET WORKSHEET (page 29)<br />
8765 West Higgins Road ● Chicago, Illinois 60631-4101 ● Phone 773-380-2700 Fax 773-380-2410 ● www.elca.org<br />
GM_ISA_04162013_v001 7
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8
International Lea<strong>de</strong>rship Development Program<br />
DESCRIPTION OF STUDY PROGRAM, AIMS AND GOALS FOR THE FUTURE<br />
(To be completed by applicant)<br />
Name of Applicant<br />
1. Description of the study or training program for which you are requesting scholarship support.<br />
2. What area of study or research do you intend to pursue? Please check one in the <strong>de</strong>gree/program box and one area of<br />
concentration.<br />
<strong>de</strong>gree/program<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
□<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
Certificate/Diploma<br />
Un<strong>de</strong>rgraduate Degree<br />
Honours<br />
Licenciatura<br />
MA — Master of Arts<br />
MDIV — Master of Divinity<br />
MTh — Master of Theology<br />
□ Graduate Certificate<br />
DMin — Doctor of Ministry<br />
PhD — Doctor of Philosophy<br />
ThD — Doctor of Theology<br />
Research Scholar<br />
Other (Please <strong>de</strong>scribe):<br />
area of concentration<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
□ □<br />
Biblical Studies: Old Testament/ New Testament/<br />
Scriptural Theology<br />
Church History/ Historical Studies<br />
Ethics/Church and Society<br />
Systematics/Constructive Theology<br />
Practical Theology (check one):<br />
□ □ Conflict Resolution □ □ Mission/Interfaith<br />
Relations<br />
□ □ Congregational &<br />
Community Care □ □ Pastoral Care &<br />
Counseling<br />
□ □ Congregational<br />
Ministries & Lea<strong>de</strong>rship □ □ Religion & Science<br />
□ □ Cross-cultural □ □ Social Work<br />
□ □ Education □ □ World Christianity<br />
□ □ Evangelism □ □ Worship<br />
□ □ Homiletics (preaching) □ □ Youth & Family<br />
□ □ Other (specify):<br />
3. Is this study program available in your home country or nearby country? If yes please explain below: □□<br />
Yes<br />
□□<br />
No<br />
4. Proposed place of study or training (Please list no more than three): 1)<br />
2) 3)<br />
5. Duration of proposed study or training:<br />
start date mm/yyyy<br />
end date mm/yyyy<br />
6. What date do you hope to begin your studies?<br />
8765 West Higgins Road ● Chicago, Illinois 60631-4101 ● Phone 773-380-2700 Fax 773-380-2410 ● www.elca.org<br />
GM_ISA_04162013_v001 9<br />
mm/yyyy
7. Have you been accepted?<br />
□□<br />
Yes<br />
□□<br />
No<br />
8. Please <strong>de</strong>scribe your future assignment in your church.<br />
(Inclu<strong>de</strong> letter of acceptance and expected start date)<br />
mm/yyyy<br />
9. How will your study program assist you in your future service to your church? How will this benefit your church?<br />
10. How would this program assist your growth as a person?<br />
11. Other comments that will assist us in un<strong>de</strong>rstanding your goals and aims for the future.<br />
GM_ISA_04162013_v001 10
Global Mission<br />
International Lea<strong>de</strong>rship Development Program<br />
PERSONAL NARRATIVE, FAITH STATEMENT AND GOALS<br />
Please write a narrative <strong>de</strong>scription of yourself (500-750 words). Provi<strong>de</strong> information about significant events of your life and a brief<br />
statement of your Christian faith. Also, inclu<strong>de</strong> your aca<strong>de</strong>mic and vocational goals and how the proposed program will affect your<br />
church's future.<br />
8765 West Higgins Road ● Chicago, Illinois 60631-4101 ● Phone 773-380-2700 Fax 773-380-2410 ● www.elca.org<br />
GM_ISA_04162013_v001 11
GM_ISA_04162013_v001<br />
12
PERSONAL COMMITMENT AGREEMENT<br />
(To be signed by applicant and returned with application)<br />
Global Mission<br />
International Lea<strong>de</strong>rship Development Program<br />
1. I promise to return to my home country as soon as my studies or other approved activities un<strong>de</strong>r the sponsorship of the<br />
Evangelical Lutheran Church in America (<strong>ELCA</strong>) have officially been terminated.<br />
2. I promise not to solicit any funds or privileges for personal/family use or for any home church personnel/projects during<br />
the period of my scholarship.<br />
3. I promise to notify the <strong>ELCA</strong> of any health changes that may occur after the issuance of the “Certificate of Health”<br />
submitted with this application.<br />
4. I promise that my <strong>de</strong>pen<strong>de</strong>nts, if any, will be a<strong>de</strong>quately cared for during my absence. I promise I will not solicit funds<br />
on their behalf.<br />
5. I promise not to make any changes in my approved study program without the prior approval of the <strong>ELCA</strong>/Global<br />
Mission Director for International Lea<strong>de</strong>rship Development. I will not seek additional studies beyond that for which this<br />
scholarship is approved.<br />
6. I promise to repay the full amount of the scholarship grant if, A) I do not fulfill all agreements ma<strong>de</strong> with my church or<br />
institution in regard to service after the completion of my study program or B) I do not fulfill all agreements ma<strong>de</strong> with<br />
the Evangelical Lutheran Church in America.<br />
7. I certify that the information in this application and appendices is true and complete to the best of my knowledge and<br />
ability.<br />
Signature<br />
Name (Please print)<br />
Date<br />
mm/dd/yyyy<br />
for gm use<br />
Director for Lea<strong>de</strong>rship Development<br />
Date<br />
mm/dd/yyyy<br />
mailing information<br />
Please save document before submitting or mail completed application to:<br />
Director for International Lea<strong>de</strong>rship Development<br />
Evangelical Lutheran Church in America - Global Mission<br />
8765 West Higgins Road<br />
Chicago, IL 60631 USA<br />
Phone: 1-773-380-2650 Fax: 1-773-380-2410 www.<strong>ELCA</strong>.org Email: Globalscholars@elca.org<br />
note: Application <strong>de</strong>adline is October 15 of each year for programs that begin after February 1 the following year.<br />
8765 West Higgins Road ● Chicago, Illinois 60631-4101 ● Phone 773-380-2700 Fax 773-380-2410 ● www.elca.org<br />
GM_ISA_04162013_v001 13
GM_ISA_04162013_v001<br />
14