DeWitt Wallace Center for Media and Democracy

DUKE UNIVERSITY
MEDIA FELLOWS PROGRAM APPLICATION

1. Name ____________________________________________________________

M ______ F ______

Mailing address _____________________________________________________________________

_____________________________________________________________________

Telephone:
_________________________________ (home)
_________________________________ (work)

Fax ___________________________

E-mail _____________________________________________

Date of birth ___________________________________________________________

Place of birth ___________________________________________________________

Citizenship _____________________________________________________________

Passport Number ________________________________________________________

Social Security Number (if applicable) _________________________________________

Web site address, personal or work, (if applicable) ________________________________

2. Employer _____________________________________________________________

Present position __________________________________________________________

Immediate Supervisor (with title) ____________________________________

Address ________________________________________________________________

_______________________________________________________________________

Nature of the work you do:

_______________________________________________________________________

3. LANGUAGES- Rate yourself: 1-Excellent 2- Good 3-Fair 4-Poor

Language	Speaking	Writing	Reading
English

For any of the following questions, please use additional paper if necessary.

4. EDUCATION AND PROFESSIONAL TRAINING

Institution	Location	Date Attended	Degree (Major)

5. PROFESSIONAL EXPERIENCE

(list previous positions in chronological order including dates.)

__________________________________________________________________________________

6. FUNDING SOURCE

Please state the source of your funding (i.e. company, foundation or scholarship, etc.)

__________________________________________________________________________________

7. STATEMENT OF PURPOSE

On a separate sheet of paper, please describe why you wish to participate in the program and what subject areas interest you most. What are your career expectations and plans for future projects?

8. SAMPLES OF WORK

Please include three samples of your work, including a brief description. For journalists, this could be three copies of your articles, audio or video tapes. Policymakers should submit copies of reports or a description of three recent projects. (If the work is not in English, please include a summary in English.)

9. REFERENCE LETTERS

Please include two reference letters, including one from your current employer.

Back to Fellows

Completed applications should be sent to:
Laurie Bley, Fellows Program Coordinator
DeWitt Wallace Center for Media and Democracy
Duke University
Box 90241
Durham, NC 27708-0241
Tel: (919) 613-7344
Fax: (919) 684-4270
media@pps.duke.edu