I. Personal Data

First Name: __________________________________________________________

Last Name: __________________________________________________________

Date of Birth: ____________ Country of Birth: _______________________

Social Security Number:_________________

Current Employer: ___________________________________

Position: ___________________________________

Business Address: ________________________________________________________

________________________________________________________________

Telephone ____________________ Fax: ____________________

E-mail: ____________________

Home Address: ____________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

Telephone: ____________________ Fax: ____________________

E-mail:____________________

Which address should we use for correspondence? Business or Home

Do you have any health condition or dietary needs that could be a factor during an extended stay abroad?

____________________________________________________________________________

____________________________________________________________________________

How did you find out about this fellowship?

____________________________________________________________________________

____________________________________________________________________________

II. Employment Experience (Begin with present position.)

a. Organization_____________________________________________________________

Dates of employment _________________________________________________________

Position ____________________________________________________________________

b. Organization_____________________________________________________________

Dates of employment _________________________________________________________

Position ____________________________________________________________________

c. Organization_____________________________________________________________

Dates of employment _________________________________________________________

Position ____________________________________________________________________

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

______________________________________________________________________________
Educational Institution Degree/Certificate Date

______________________________________________________________________________
Educational Institution Degree/Certificate Date

______________________________________________________________________________
Educational Institution Degree/Certificate Date

IV. International Experience (Briefly describe any overseas work or travel.)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

V. Teaching or Consulting Experience (Briefly describe any training or consulting experience that may be relevant to the fellowship mission.)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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

______________________________________________________________________________
Award/Fellowship Grantor Date

______________________________________________________________________________
Award/Fellowship Grantor Date

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

______________________________________________________________________________
Native Language

______________________________________________________________________________
Other language Spoken fluency: poor, fair, good, excellent Written fluency: 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 McGee Journalism Fellowships in Southern Africa. Be sure to include the specific professional expertise you wish to share with colleagues in the region. While the fellow is likely to be sent to Botswana, you may discuss where you would like to be posted.

VIII. References

You must have three letters of recommendation sent to ICFJ. Your references may be called. Please list contact information for each reference:

a. Name: _______________________________ Position: ___________________

Address:___________________________________________________________

Telephone:__________________________________

b. Name: _______________________________ Position: ___________________

Address:___________________________________________________________

Telephone:__________________________________

c. Name: _______________________________ Position: ___________________

Address:___________________________________________________________

Telephone:__________________________________