Family Name:

Given Name:

Office Location and Number (e.g., Craven 5313):

Office Telephone:

E-Mail Address:

Academic Program or Discipline:

Specialization Within Discipline:

Regional Specialization or Interest (if any): (Select one or more) None Latin America Sub-Saharan Africa Middle East and North Africa East Asia South Asia Western Europe Central Europe Russia and NIS North America

Country Specialization(s) (if any):

Language Proficiency (If you are able to communicate in languages other than English, please enter them in the boxes below and indicate your level of proficiency in each):

    Native Fluency    Fluent    Basic Ability to Communicate

    Native Fluency    Fluent    Basic Ability to Communicate

    Native Fluency    Fluent    Basic Ability to Communicate

    Native Fluency    Fluent    Basic Ability to Communicate

Country of Birth (Optional):

If you are from the United States and were educated here, did you ever study abroad for a period of a month or more?  Yes     No.  If yes, where:

If you are from a country other than the United States, did you attend a college or university in the U.S. as an "international student"?  Yes    No.  If yes, would you be interested in serving as a "mentor" to a CSUSM international student?  Yes    No.

Have you ever resided outside the United States for more than a month for the purpose of doing research or teaching? Yes     No. If yes, where: ?

Do you have "contacts" or links with academic institutions abroad that might be used to contribute to  campus globalization activities, such as faculty and student exchange or international student recruitment? Yes     No.  If yes, which institution(s) and where are they located?