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Douglas Tweedale Memorial Fellowship

APPLICATION DEADLINE: JULY 15, 2007

I - PERSONAL DATA LAST NAME:*
FIRST NAME:*
GENDER (M/F):*
DATE OF BIRTH:*
CITIZENSHIP/PASSPORT NUMBER:*
CURRENT EMPLOYER:*
CURRENT POSITION:*
BUSINESS ADDRESS:*
TELEPHONE:*
FAX:*
OTHER (E-MAIL, ETC.):*
HOME ADDRESS:*
TELEPHONE:*
FAX:*
OTHER (E-MAIL, ETC.):*
PLEASE INDICATE ADDRESS WE SHOULD USE FOR CORRESPONDENCE:HOME:WORK:*
How did you hear about the program?From ICFJ fellowship alumniFrom ICFJ newslettersICFJ Website or IJNetOther*

II - EMPLOYMENT EXPERIENCE HOW MANY YEARS HAVE YOU WORKED AS A JOURNALIST?:*

CURRENT EMPLOYER: ORGANIZATION:*
POSITION:*
DATES:*
TYPE OF MEDIA (NEWSPAPER, TV, ETC.):
CIRCULATION:*
PUBLIC OR PRIVATE OWNERSHIP:*
NUMBER OF JOURNALISTS IN NEWSROOM:*
DAYS PER WEEK YOUR PUBLICATION IS DISTRIBUTED/AIRED:*
PLEASE DESCRIBE YOUR ORGANIZATION:*

PREVIOUS EMPLOYERS: ORGANIZATION:*
POSITION:*
DATES:*
ORGANIZATION:*
POSITION:*
DATES:*

III - EDUCATION BRIEFLY LIST ANY HIGHER EDUCATION DEGREES, INSTITUTIONS AND DATES.*

IV - INTERNATIONAL EXPERIENCE
BRIEFLY DESCRIBE ANY OVERSEAS WORK OR TRAINING, INCLUDING ALL *

VI - ESSAY

PLEASE ATTACH A ONE-PAGE ESSAY EXPLAINING WHY YOU WISH TO PARTICIPATE IN THE PROGRAM, WHAT YOU WANT TO LEARN DURING THE INTERNSHIP IN THE UNITED STATES AND LATIN AMERICA, AND HOW THE EXPERIENCE WILL HELP YOUR NEWS ORGANIZATION.

VII - SAMPLES OF WORK

PRINT MEDIA APPLICANTS SHOULD SUBMIT 3-5 EXAMPLES OF ARTICLES THEY HAVE WRITTEN. TV APPLICANTS SHOULD SUBMIT 3-5 WRITTEN TRANSCRIPTS OF THEIR PROGRAMS.

Completed applications must be submitted on or before July 15, 2007 to: David Blanco, Program Officer International Center for Journalists 1616 H Street, NW Third Floor Washington, DC 20006 USA Tel: (202) 737-3700 / Fax: (202) 737-0530 E-mail: tweedale@icfj.org Web Sites: www.icfj.org / www.ijnet.org

AGREEMENT TO PROGRAM CONDITIONS

I, the undersigned, understand and agree to the following conditions of the 2005 Douglas Tweedale Memorial Fellowship:

. If chosen to be a participant, I will be required to spend six weeks full-time in the United States and another country in Latin America, participating in all aspects of the fellowship.
. I fully understand and agree that it is a condition of this fellowship that spouses or dependants cannot be included nor be accommodated in the program. . The organizers will pay for round-trip economy air fare to and from the United States and the site of the second program attachment in Latin America; program-related travel expenses within the United States and the site of the second program attachment; a housing and meal allowance; and health insurance for the duration of the program. I will assume responsibility for all incidental expenses. . If chosen, I will be responsible for all passport and visa arrangements, and required fees. . If chosen, I am required to return to my home country and my current employment after the completion of the program.

Participation in this program is contingent upon my ability to meet all requirements. I certify that all statements in my application are true, to the best of my knowledge. I understand that any participant who violates this rule will be expelled from the program.*
SIGNATURE:*
DATE:*

EMPLOYER'S STATEMENT:

(nombre del aplicante)

Yo, el abajo firmante y empleador de:*
un aplicante en el Douglas Tweedale Memorial Fellowship de 2005, estoy enterado de que si �l/la aplicante es aceptado(a) que �l/ella tendr� que permanecer por seis semanas en los Estados Unidos y en otro pa�s en Am�rica Latina. Yo estoy deacuerdo con eximirlo(a) de sus responsabiidades rutinarias y aseguro que no le asignar� ning�n proyecto especial que interfiera con este programa. Adem�s, yo entiendo que los participantes del programa deben retornar a su posici�n original. Yo, mantendr� la posici�n del aplicante hasta que el progama haya concluido. *
Nombre:*
Fecha: *
Firma:*
Tel�fono:*
Organizaci�n: *

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