(This form must be notarized)

I. Personal Data

Last Name:____________________________________________

First Name: ______________________________

Date of Birth: ___________________________

Country of Birth: __________________________

Social Security Number:___________________________

Spouse's Name (If applicable): ____________________________

Current Employer: __________________________________________________

Position:___________________________________

Business Address: __________________________________________________________

____________________________________________________________________________

_______________________________________________________________

Business Telephone: ______________________________

Business Fax: ______________________________

Home Address: _____________________________________________________

________________________________________________________________

________________________________________________________________

Home Telephone: ________________________________________________

Home Fax: _____________________________________________________

E-mail address (Business/Home)________________________________________

Which address should we use for correspondence? (circle one)
Business \ Home

Do you have any health conditions or dietary needs that could be a factor during an
extended stay abroad? Please explain.

____________________________________________________________________________

____________________________________________________________________________

Do you anticipate anyone (spouse, family member or other individual)
traveling with you during the Fellowship? Please give name and relationship.

____________________________________________________________________________

II. Employment Experience (Begin with present position.)

Dates of employment: ______________________________

b. Organization: _____________________________________________

Dates of employment: ______________________________

c. Organization _____________________________________________

Dates of employment: ______________________________

III. Education (Briefly list any higher education degree or certificates.)

Degree:__________________

Dates: _________________________________

b. Educational Institution: _________________________________________

Degree:__________________

Dates: _________________________________

c. Educational Institution: _________________________________________

Degree:__________________

Dates: _________________________________

IV. Awards and Fellowships
(Briefly list any awards or fellowships you have received.)

Award/Fellowship____________________________________________ Grantor/Date:__________________

Award/Fellowship____________________________________________ Grantor/Date:__________________

Award/Fellowship____________________________________________ Grantor/Date:__________________

V. International Experience

a. Briefly describe any overseas work or travel.

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

b. If you are granted a fellowship, where do you want to go and why?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

VI. Language Skills (If you speak more than one language, rate your fluency)

Language: _______________________________________________
Spoken fluency (choose one): Poor _____ Fair _____ Good _____ Excellent_____
Written fluency (choose one): Poor _____ Fair_____ Good _____ Excellent_____

Language: _______________________________________________
Spoken fluency (circle one): Poor_____ Fair_____ Good _____ Excellent _____
Written fluency (circle one): Poor_____ Fair_____ Good _____ Excellent _____

VII. Reasons for Applying

On no more than three separate sheets of paper, please explain your reasons
for applying for the Ford Environmental Journalism Fellowship. Be sure to cover
the following areas:

• Preferred destination and why
• Preferred duration abroad (not to exceed 90 days)
• The specific professional expertise you wish to share with overseas colleagues
• Any writing project you wish to undertake during the Fellowship.

VIII. References
You must submit three letters of recommendation. Your references may be called. Please list contact information for each reference:

a. Name:___________________________________________

Title:____________________________________

Organization: ______________________________

Address ________________________________________________

Telephone: ______________________________________

b. Name:___________________________________________

Organization: ______________________________

Title:______________________________________

Address ________________________________________________

Telephone: ______________________________________

c. Name:______________________________________

Title:______________________________________

Organization: ______________________________

Address ________________________________________________

Telephone: ______________________________________

IX. Work Samples
Enclose two samples of your work (e.g., clips, tapes, videos)

X. Statement of Understanding
Applicants are required to comply with the attached Statement of Understanding.

Applicant's Signature: __________________________________________________________

Date: _________________________________

Notary: