International House Application for Program & Resident Fellowships Spring 2014 Last Name: Room #: First Name: ____________________________ Cell phone #: Email (Preferred): ______________________________________________________________ Country of Origin: ___________________ Permanent Residence: Date of first arrival at I-House: ___________________________ Field of Study/Concentration: _________________________________________________________ Academic/Training Institution during the 2013-14 academic year: ___________________________________ Degree & Expected Graduation Date:___________________________________________________________ Status for the next academic year (circle one): Student Trainee Intern Scholar Other:_______________ NOTE: You must apply and be approved by the Admissions Office for resident membership for the 2013–2014 Academic Year to be eligible for a fellowship position. If you have any questions about your status, please contact the Admissions Office. Please list I-House Scholarships and/or Program/Resident Fellowships, including dates: Please list I-House programs and activities you have participated in as a resident member including any leadership roles/positions: Why is this fellowship of interest to you? Continue to next page On a separate sheet of paper, please describe your interests, skills and experiences that qualify you for each of the fellowships for which you are applying. Please attach your resume or C.V. Please list any outside commitments you will have next year. Include employment, internships, etc. Please list at least one professional reference whom we may contact if you are a finalist for a fellowship. Please give the person’s name, relationship to you, and telephone number and e-mail address: Name & Title: ____________________________________________________________________ Relationship: __________________________________ Telephone: ____________________ E-mail address: _________________________________ Mandatory Dates All Resident Fellows, Equipment Technicians, and Program Fellows (except Summer Fellows) are required to attend Team Training and Leadership Weekend. These dates are as follows: Program Fellow Team Meetings: 1/21; 2/25; 3/25; 4/22; All Nations Celebration: 4/5 Do you foresee any conflicts in your schedule with these dates? _____________________________ All the information submitted here is true and accurate. If selected, I understand that my name and photo/video may be used for Programs publicity purposes. Signature______________________________________________ Date____________________ Please return this form with a statement describing your interest in the Fellowships you are applying for and a copy of your resume/CV to the Programs & Resident Life Office or email it to email@example.com.