2019 Fellowship Application

First Name
Last Name
Your Email

Permanent Address

City/State
Zip Code

Present Address

City/State
Zip Code

Primary (Day) Phone
Secondary (Cell) Phone

Employment History

List your last 3 employers or volunteer activities. Start with the most recent, include any military experience.

Reference 1

Company Name (Most Recent)
Current or Most Recent Position
Contact phone number
Your immediate supervisor
City/State
Date Worked From:
Date Worked To:
Last Annual Salary
Reason for Leaving
May We Contact This Employer
YesNo
Full or Part Time
Full TimePart Time
Short description of your responsibilities

Reference 2

Company Name (Most Recent)
Current or Most Recent Position
Contact phone number
Your immediate supervisor
City/State
Date Worked From:
Date Worked To:
Last Annual Salary
Reason for Leaving
May We Contact This Employer
YesNo
Full or Part Time
Full TimePart Time
Short description of your responsibilities

Reference 3

Company Name (Most Recent)
Current or Most Recent Position
Contact phone number
Your immediate supervisor
City/State
Date Worked From:
Date Worked To:
Last Annual Salary
Reason for Leaving
May We Contact This Employer
YesNo
Full or Part Time
Full TimePart Time
Short description of your responsibilities

Education

College, Universities, and Technical Schools Attended

School #1

Name and Location
Date Attended From:
Date Attended To:
Major Areas of Study
Minor Areas of Study
Overall GPA
Degree Attained
Date Conferred or Expected

GraduateUndergraduate

School #2

Name and Location
Date Attended From:
Date Attended To:
Major Areas of Study
Minor Areas of Study
Overall GPA
Degree Attained
Date Conferred or Expected

GraduateUndergraduate

School #3

Name and Location
Date Attended From:
Date Attended To:
Major Areas of Study
Minor Areas of Study
Overall GPA
Degree Attained
Date Conferred or Expected

GraduateUndergraduate

School #4

Name and Location
Date Attended From:
Date Attended To:
Major Areas of Study
Minor Areas of Study
Overall GPA
Degree Attained
Date Conferred or Expected

GraduateUndergraduate

Graduate

Number of Graduate Hours Beyond Graduate of Your Highest Degree

List Honors, Awards, or distinctions you have earned:

Please describe an overview of your published writing, including date, publication, description, and awards. Provide a link to those publications if possible.

Upload three samples of your best work (unless you provided links to the work above).

Certification

Do you hold a teaching certificate?
YesNo

Extracurriculars

Statement

As a student what teacher had the greatest influence on you and why?
What would you tell high school creative writing students(juniors and seniors) about the importance of being able to communicate creatively in their lives?

Professional References

Reference #1

Name
School/Organization
Reference Current Position
Reference Cell Phone
Reference Work Phone
Email
Relationship

Reference #2

Name
School/Organization
Reference Current Position
Reference Cell Phone
Reference Work Phone
Email
Relationship

Reference #3

Name
School/Organization
Reference Current Position
Reference Cell Phone
Reference Work Phone
Email
Relationship

Additional Information

Disclosures

Are you currently under contract?
YesNo
Have you ever had a teaching certificate or teaching license revoked?
YesNo
Are you a relative of any board member, administrator, or supervisor who is currently serving either the National Writers Series, the Front Street Writers, or the Traverse Bay Area Intermediate School District or Its Career Tech Center?
YesNo

Legal Information

Are you eligible to work in the United States?
YesNo
Have you ever been convicted of a criminal offense other than a minor traffic violation?
YesNo
Have you ever had any indicated finding of child abuse filed in your name:
YesNo
Does your name appear on any Sex Offender Database in any state or country?
YesNo
Resume Upload: (Optional)
Type your Name in the box below as digital signature:
On which website did you find this job posting?
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