DUKE UNIVERSITY MEDIA FELLOWS PROGRAM APPLICATION

1. PERSONAL DATA

Name

M

F

Mailing address
Home Telephone
Work Telephone
Fax
Email
Date of birth
Place of birth
Citizenship
Passport nr.

Social Security Number (if applicable)
Personal or work website (if applicable)	http://

2. EMPLOYER

Present position
Immediate supervisor (with title)

Mailing 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.

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 Back to Fellows