1. Ford Motor Company
International Fellowship of the
92nd Street Y
Year Eleven: Developing Community Leaders
June 2 - June 22, 2011
Application Form
You must be fluent in English to be considered for admission. Please type or
print, complete the application form in its entirety, and supply all necessary
attachments in order for your application to be reviewed.
Personal Information
Last name (family name):
First name (given name):
Home address [type the address as it should appear on an envelope]:
Postal Code:
Phone number:
Fax number:
Work address [type the address as it should appear on an envelope]:
Postal Code:
Phone number:
Fax number:
Which address would you prefer we send mail to? HOME WORK
Email address:
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2. Date of birth (month/day/year):
Sex: MALE FEMALE
Original language:
Other languages spoken (aside from English):
Do you have a valid passport?
Please indicate two emergency contacts:
1) Name:
Address:
Phone number:
Relationship to you:
2) Name:
Address:
Phone number:
Relationship to you:
How did you hear about this fellowship?
Educational Background
Name of school:
City:
Country:
Dates attended:
Area of study:
Type of degree:
Honors, awards, other:
Name of school:
City:
Country:
Dates attended:
Area of study:
Type of degree:
Honors, awards, other:
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3. Employment History
Current or most recent position:
Type of job/title:
Responsibilities:
Name of organization:
Address of organization:
Dates of employment:
Full or part time?
Previous positions [list each]:
Type of job/title:
Responsibilities:
Name of organization:
Address of organization:
Dates of employment:
Full or part time?
Type of job/title:
Responsibilities:
Name of organization:
Address of organization:
Dates of employment:
Full or part time?
Other Relevant Experience
Describe any volunteer experience, community involvement, etc.
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4. Health and Medical Information
Do you have any physical, emotional, or psychological conditions that we should
be aware of?
If so, please describe:
Do you have any dietary restrictions and/or allergies?
Do you have health and/or medical insurance?
Type of coverage:
Provider:
Policy number:
References
Please enclose two letters of recommendation in envelopes sealed and signed
across the seals by your references. Your references may also send letters to us
directly. Each letter should be written by an employer, educator, or counselor
who has known you in a professional or academic capacity for more than six
months. Letters from personal references (family members or friends) will not be
accepted. Please list your two references below so that we may contact them.
1) Name:
Title:
Organization name:
Address:
City:
Country:
Postal Code:
Phone number:
Fax number:
Email address:
2) Name:
Title:
Organization name:
Address:
City:
Country:
Postal Code:
Phone number:
Fax number:
Email address:
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5. Computer Access
Do you have access to a computer and the Internet?
Where? AT HOME AT WORK OTHER
Other Fellowships
Are you currently a recipient of another fellowship?
Have you been a fellowship recipient in the past?
If so, what was the name and nature of the program?
Attachments
Please include the following attachments with your completed application form:
 Cover Letter. Include how you learned about the Ford Motor Company
International Fellowship of the 92nd Street Y.
 Resume or Curriculum Vitae
 Two-page Essay. In narrative form, describe your background and your
reasons for wanting to participate in this program. Also, describe in detail
issues affecting the well-being and stability of your community. (Examples
include inter-group conflict, community health concerns, youth
development, and environmental matters.) Then answer the following
questions: What outcome do you hope for? What role do you wish to play
in that outcome? What skills do you feel you need to make the desired
outcome happen?
 Two Reference Letters. Letters should be written by professional or
academic references. They may be enclosed with your application or sent
separately by your references. (For more information, please see the
“References” section on the previous page.)
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6. Deadline for Submission
APPLICATIONS MUST BE EMAILED OR POSTMARKED BY June 30, 2010.
You will be notified of receipt of your application, and you will be apprised of the
status of your application by December 31, 2010.
This program is a rigorous learning opportunity. It requires completion of
written assignments prior to and following the residency, full participation
in all classes and group activities while in New York, and a commitment to
remain involved in the program’s future as we build a growing network of
community leaders throughout the world.
Submit your completed application along with all required attachments to:
fordfellowship@92Y.org
Or post-mail to:
Ford Motor Company International Fellowship of the 92nd Street Y
92nd Street YM-YWHA
1395 Lexington Avenue
New York, NY 10128
USA
Phone: 212.415.5473
Fax: 212.415.5798
Email: agardy@92Y.org
Website: www.92Y.org/ford
Ford Motor Company reserves the right to information from this application for
their internal tracking purposes.
The 92nd Street YM-YWHA is an agency of UJA-Federation.
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