DS-4297 FLO Professional Development Fellowship

OMB APPROVAL NO. 1405-0229
EXPIRATION DATE: 01-31-2021
ESTIMATED BURDEN: 2.75 Hours

U.S. Department of State

FLO Professional Development Fellowship (PDF) Application Form

By submitting this application, if selected for funding, I consent to the publication of my name by the Department as a recipient of a FLO Professional
Development Fellowship and to quote my comments about my experience in relevant publications.

Initial Here
Please read carefully and follow the instructions linked below. Applications that are late, incomplete, or contain ineligible expenses will not
be considered.
PDF Form Instructions
SECTION I: PERSONAL DATA
Last Name

First Name

Title (Optional)

_
Email - Personal

Email - Work (Official - Optional)

Check one:
Eligible Family Member Spouse

Member of Household Partner

Check all that apply:
First-time fellowship applicant

Prior fellowship applicant

Prior fellowship recipient (Select all applicable fellowship period(s)):

2020-2021

2020-2021

2024-2025

If you were a prior recipient, how did you use your PDF? (maximum 250 characters)

Employee Sponsor Last Name

Employee Sponsor First Name

Employee Sponsor Email - Work (Official)

Employee Sponsor Agency

Employee Sponsor Agency "Other"

(Make Selection) (Make Selection)
Employee Sponsor Post(s) of Assignment during PDF Period

Dates of Assignment during PDF Period (MM/YYYY)

MM

2027

to

MM

2027

Is your spouse assigned to an unaccompanied tour (UT) during the PDF period?
Yes
DS-4297
11-2017

Where will you reside overseas during PDF period?
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SECTION II: PROPOSAL DESCRIPTION
A. Project Type
Please select one (For more than one select "Other")

(Make Selection)
B. Proposal Synopsis
Include only project activities that take place during the fellowship period (maximum 400 characters)

C. Background
Summary of your professional background (maximum 1700 characters)

Current challenges in pursuing career goals (maximum 1700 characters)

DS-4297

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SECTION Ill: DETAILED DESCRIPTION OF PROPOSED PROJECT
Include only project activities that take place during the fellowship period. Include links for activities and costs in the chart below your
description. (maximum 3000 characters total)

Name of Provider

DS-4297

Link to Project Activity

Link to Cost

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SECTIONIV : BUDGET
Include only eligible project expenses for activities that occur during the fellowship period.
Please see instructions for eligible expenses.

1. Itemized breakdown of allowable reimbursable project expenses:

$0

$0
$0
$0
$0

$0
Total Reimbursable Project Expenses

$0

1

$0

A

2. Calculate minimum amount of Applicant Responsibility and Requested Fellowship Amount:
Total Reimbursable Project Expenses (from #1. above)
25% Applicant Responsibility: A x 25%

B

A-B

C

Enter Requested Fellowship Amount*

$0

Remaining Additional Self-Funded Costs (if any) C - D

D
E

* Maximum reimbursable PDF fellowship amount is $2,500 and minimum is $1 ,000.

SECTION V: COMPLETION
Future plans if offered fellowship (maximum 500 characters):

**Please save your application as LastNameFirstlnitial (ie. Jane Doe = DoeJ.pdf) and email to the address listed in the INSTRUCTIONS .
**Applications are due to FLO no later than the date indicated in the instructions. Applications that are late, incomplete, or contain ineligible
expenses will not be considered.

Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 2.75 hours per response, including time required for searching existing data
sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to
supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate
and/or recommendations for reducing it, please send them to Family Liaison Office, 2201 C Street NW, Room 2133, Washington, DC 20520.
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to 22 U.S.C. § 4026(b) (Establishment of the Family Liaison Office), 22 U.S.C. § 2651a (Organization of
the Department of State), and 22 U.S.C. § 3921 (Management of the Foreign Service).
PURPOSE: The information solicited on this form will be used to award Professional Development Fellowships to Eligible Family Members and Members of
Household of employees of U.S. foreign affairs agencies to support them in their effort to develop, maintain, and/or refresh their professional skills while
overseas.
ROUTINE USES: Uses for the system can be found in the System of Records Notice, State-31, Human Resources Records.
DISCLOSURE: Providing this information is voluntary. However, failure to provide the information requested on this form may affect the applicant's eligibility
to participate in the PDF program.
DS-4297

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