Five College African Scholars Program Application for ResidencyDeadline May 15, 2006 Term for which you are applying (check only one) ____ Mid-January to May 2007 ____Mid-August to December 2007 ____ Either term: Mid-January to May or Mid-August to December, 2007 Family Name: ________________________________________________ Other Names: ________________________________________________ Citizenship: ___________________ Circle one: Female / Male Highest Degree: ___________________________________ Age:____ Current Position: _____________________________________________ Department: __________________________________________________ University: ___________________________________________________ University Address: _______________________________________________ ____________________________________________________________ Optional - Preferred Mailing Address:_______________________________________________ ____________________________________________________________ Telephone: _______________________ Cell: _______________________ E-mail: ____________________________Fax: ________________________ During the past two years, have you resided in Europe or North America? Circle one: Yes / No If yes, please indicate the dates: _________________________ Have you resided in the USA with a J-1 visa during the past 12 months? Circle one: Yes / No Title of proposed project: ______________________________________ ___________________________________________________________ Applications must include:
Applications may be sent by mail, by fax or by email. Applications for 2007 terms must be received by 1 May, 2006. Please put your name in the subject line for email. A confirmation of receipt will be sent once all your documents have been submitted. When awarded a fellowship, selected residents must provide a signed statement from the chief academic officer at their university, indicating academic position, granting academic leave during the residency, and certifying the right to return to this position afterwards. Send to:
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