Frederick
Douglass Teaching Scholars
Summer 2007
APPLICATION
Clarion University
of Pennsylvania
__________________________________________ ____________________
Name Social Security Number
__________________________________________________________________
Address
(Street)
__________________________________________________________________
(City) (State) (Zip Code)
Phone (____)_____________ (Work) Phone (____)_____________ (Home)
Fax
(___)________________
E-mail Address _____________________________________________________
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What
is your active degree status? ABD __ Ph.D.
___
Program___________________________________________________________
University__________________________________________________________
City
_______________________________
State____________
Expected
date of degree completion __________________________________
(Month) (Year)
Please
indicate your current situation:
__ Taking course work in a doctoral/terminal program.
Have completed required course work in a doctoral/terminal program, but have not
__ passed oral exam
__ Have passed oral exams and working on doctoral dissertation
__ Other (indicate status) _____________________________________________________
Name of your major advisor: __________________________________________
Major
advisor’s mailing address: _______________________________________
__________________________________________________________________
Major
advisor’s phone number: (___)____________________
fax:
(___)____________________
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Do your future plans include teaching in higher education? __ Yes __ No
Do you have college or university teaching experience? ___ Yes ___ No
If yes, please describe: ___________________________________________________________
______________________________________________________________________________
__________________________________
Signature of Applicant
Optional Response: How did you learn about this fellowship?
Advertisement (Source): ______________________________
Posting (Where Posted): ______________________________
Other (Please Specify): ______________________________
NOTE: This application must be accompanied by:
¨ A full
curriculum vitae with a letter of
interest
¨ A copy of your graduate
transcript. (This can be a copy
of the official transcript).
¨ A letter from your major or
dissertation advisor regarding your qualifications for this program.
¨ A letter from at least two
additional references regarding your experience and ability. (If you had teaching experience, this letter
should include information relative to that experience.)
SEND THIS
APPLICATION AND RELATED MATERIALS TO:
The Frederick Douglass
Teaching Scholars
Office of Social Equity, 207
Carrier Hall
APPLICATION AND RELATED MATERIALS SHOULD BE POSTMARKED BY:
February 2, 2007
CANDIDATES
ARE USUALLY NOTIFIED OF THE UNIVERSITY’S DECISION IN EARLY APRIL 2007
Questions: Please call: (814) 393-2109 or refer to http://www.clarion.edu/admin/socequ/fd1.shtml
An Affirmative Action/Equal