# Ford Motor Company

International Fellowship of the

92nd Street Y

Year Eight: Developing Community Leaders

June 6-June 25, 2008

**Application Form**

You must be fluent in English to be considered for admission. Please
type or print, complete the application form in its entirety, and supply
all necessary attachments in order for your application to be reviewed.

## Personal Information

Last name (family name):

First name (given name):

> **Home address** \[type the address as it should appear on an
> envelope\]:
>
> Postal Code:
>
> Phone number:
>
> Fax number:
>
> **Work address** \[type the address as it should appear on an
> envelope\]:
>
> Postal Code:
>
> Phone number:
>
> Fax number:

Which address would you prefer we send mail to? HOME WORK

Email address:

Date of birth (month/day/year):

Sex: MALE FEMALE

Original language:

Other languages spoken (aside from English):

Do you have a valid passport?

Please indicate two emergency contacts:

> 1\) Name:
>
> Address:
>
> Phone number:
>
> Relationship to you:
>
> 2\) Name:
>
> Address:
>
> Phone number:
>
> Relationship to you:

How did you hear about this fellowship?

## Educational Background

Name of school:

City:

Country:

Dates attended:

Area of study:

Type of degree:

Honors, awards, other:

Name of school:

City:

Country:

Dates attended:

Area of study:

Type of degree:

Honors, awards, other:

## Employment History

Current or most recent position:

> Type of job/title:
>
> Responsibilities:
>
> Name of organization:
>
> Address of organization:
>
> Dates of employment:
>
> Full or part time?

Previous positions \[list each\]:

> Type of job/title:
>
> Responsibilities:
>
> Name of organization:
>
> Address of organization:
>
> Dates of employment:
>
> Full or part time?
>
> Type of job/title:
>
> Responsibilities:
>
> Name of organization:
>
> Address of organization:
>
> Dates of employment:
>
> Full or part time?

## Other Relevant Experience

Describe any volunteer experience, community involvement, etc.

## Health and Medical Information

Do you have any physical, emotional, or psychological conditions that we
should be aware of?

If so, please describe:

Do you have any dietary restrictions and/or allergies?

Do you have health and/or medical insurance?

Type of coverage:

Provider:

Policy number:

## References

Please enclose two letters of recommendation in envelopes sealed and
signed across the seals by your references. Your references may also
send letters to us directly. Each letter should be written by an
employer, educator, or counselor who has known you in a professional or
academic capacity for more than six months. Letters from personal
references (family members or friends) will not be accepted. Please list
your two references below so that we may contact them.

1)  Name:

> Title:
>
> Organization name:
>
> Address:
>
> City:
>
> Country:
>
> Postal Code:
>
> Phone number:
>
> Fax number:
>
> Email address:

2)  Name:

> Title:
>
> Organization name:
>
> Address:
>
> City:
>
> Country:
>
> Postal Code:
>
> Phone number:
>
> Fax number:
>
> Email address:

## 

## Computer Access

Do you have access to a computer and the Internet?

Where? AT HOME AT WORK OTHER

## Other Fellowships

Are you currently a recipient of another fellowship?

Have you been a fellowship recipient in the past?

If so, what was the name and nature of the program?

## Attachments

Please include the following attachments with your completed application
form:

-   **Cover Letter.** Include how you learned about the Ford Motor
    Company International Fellowship of the 92nd Street Y.

-   **Resume or Curriculum Vitae**

-   **Two-page Essay**. In narrative form, describe your background and
    your reasons for wanting to participate in this program. Also,
    describe in detail issues affecting the well-being and stability of
    your community. (Examples include inter-group conflict, community
    health concerns, youth development, and environmental matters.) Then
    answer the following questions: What outcome do you hope for? What
    role do you wish to play? What skills do you feel you need to make
    the desired outcome happen?

-   **Two Reference Letters.** Letters should be written by professional
    or academic references. They may be enclosed with your application
    or sent separately by your references. (For more information, please
    see the "References" section on the previous page.)

## 

## Deadline for Submission

**APPLICATIONS MUST BE POSTMARKED BY June 30, 2007.**

You will be notified of receipt of your application, and final
notification of awards will be postmarked by December 31, 2007.

**Please understand that this program is a rigorous learning
opportunity. It requires completion of written 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.**

Submit your completed application along with all required attachments
to:

**Ford Motor Company International Fellowship of the 92nd Street Y**

92nd Street YM-YWHA

1395 Lexington Avenue

New York, NY 10128

USA

Phone: 212.415.5473

Fax: 212.415.5798

Email: agardy@92Y.org

Website: www.92Y.org/ford

*Ford Motor Company reserves the right to information from this
application for their internal tracking purposes.*

*The 92nd Street YM-YWHA is an agency of UJA-Federation.*