Contact Information

APPLICATION

Application Deadline

All materials must be emailed or postmarked by no later than June 30, 2013. Materials may be emailed to FordFellowship@92Y.org.

Application Instructions

Please fill out this form clearly and completely and return it, along with your cover letter, curriculum vitae, and two-page essay, by the application deadline.

We also require two letters of recommendation, which must be sent to us directly and privately by your references. Please see the Submission Guidelines section at the end of this form for instructions.

Event Date and Location

New York City, NY, USA

May 28 – June 19, 2014

Eligibility

In order to be eligible for this fellowship, you must be:

1. At least 21 years old (by June 1, 2014)

2. Fluent in English

3. Living and working in one of the 2014 Participating Countries

The 2014 countries are: Brazil, P.R. China, Dominican Republic, Haiti, India, Israel, Myanmar, Russian Federation, Senegal, and Turkey. No additions/exceptions will be made.

Expectations

This program is a rigorous learning opportunity. It requires completion of reading, writing, and group assignments prior to and following the residency, full participation in all classes and group activities while in New York, and a commitment to remain involved in the program’s future as we build a growing network of community leaders throughout the world.

Part 1: Personal & Contact Information

Personal Information

1. Last Name (family name):

2. First Name (given name):

3. Date of birth (month/day/year):

4. Gender: Male Female

5. Original language:

6. Other languages spoken (aside from English):

7. Do you have a valid passport? Yes No

Contact Information

8. Preferred email address:

9. Home Contact Information:

Full address:

Country:

Postal Code:

Home phone number:

Home fax number:

10. Work Contact Information:

Full address:

Country:

Postal Code:

Work phone number:

Work fax number:

11. Which address would you prefer we send mail to? Home Work

Emergency Contacts

12. FirstEmergency Contact:

Name:

Relationship to you:

Address:

Country:

Postal Code:

Phone number:

Email:

13. SecondEmergency Contact:

Name:

Relationship to you:

Address:

Country:

Postal Code:

Phone number:

Email:

Part 2: Education & Fellowships

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