SOROPTIMIST FOUNDER REGION FELLOWSHIP APPLICATION FORM
Miss/Ms./Mrs. ___________________________________________________________________
(Circle one)
First
Middle
Last
Address: _______________________________________________________________________
Street Address or P.O. Box, including any c/o or Unit number:
_______________________________________________________________________________
Telephone:
Home: (
) ______________________
Cell: (
) _____________________
Email address: ______________________________ Citizenship ________________________
Field of Study: _______________________ Date of Advancement to Candidacy: ____________
Title of Dissertation: _______________________________________________________________
Name of Institution you are attending: ________________________________________________
Period of Enrollment (total number of months you will be enrolled): _________ Units Completed ________
Units Remaining: _________
Anticipated Date of Completion: __________________________
ALL OF THE FOLLOWING ITEMS MUST BE INCLUDED WITH THE APPLICATION OR THE ENTIRE PACKAGE WILL BE DISQUALIFIED.
1. Description of dissertation: Submit a minimum of 3, maximum of 5 pages, double spaced, 12 pt. font.
a. Include a comprehensive statement of purpose and HOW YOUR AREA OF STUDY IMPROVES
THE LIVES OF WOMEN AND GIRLS OR CONTRIBUTES TO THE WELFARE OF HUMANITY.
2. Autobiographic sketch: Submit a maximum of 5 pages, double spaced, 12 pt. font.
a. Include family background, extracurricular activities, hobbies, interests, etc.
3. Fully completed “Estimated Monthly Expenses and Income for the Fiscal Year” form.
4. Certified transcripts of all graduate work completed and proof of university registration.
5. Statement of your advancement in the doctoral program: orals, language requirements, dissertation.
6. Two confidential letters of recommendation. They may be sent separately, postmarked by Jan 15.
Doctoral Committee Chair Name: ______________________________Phone:_________________
Faculty Member Name: _____________________________________Phone:_________________
Material other than letters of recommendation and transcripts must be sent in a single mailing to the Fellowship
President at the address below. All material must be postmarked no later than January 15th, 2016. Any material
postmarked after that date will not be accepted. Failure to comply with these requirements will result in
disqualification. Send to:
Carol Steele, President Founder Region Fellowship
19201 Pine Tree Ln Fort Bragg, CA, 95437-9231
Tel.: (707) 964-5469 Fax: same tel. (call first) Email: moneybags35@netzero.net
I CERTIFY THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE AND CORRECT AS OF THE DATE BELOW.
Signature: ________________________________________ Date: ______________________
NOTE: Semifinalists will be required to appear for a personal interview March 5, 2016 for Hawaii candidates,
and March 11-13, 2016 for Mainland candidates. Finalists will be notified and invited to attend the Soroptimist
Founder Region Conference in San Ramon, California to be recognized by the membership on Friday evening,
April 29, 2016 and to receive their awards.
REV. 6/2015