Frederick Douglass Teaching Scholars

         Summer 2009 Application

            Application Deadline: Priority consideration given to completed applications postmarked by November 1, 2008

             Name:                                                                                                                                                                                   

(Last)                                                     (First)                                      (Middle)

             Address__________________________________________________________________________________

(Street, Apartment or P.O. Box Number)

                                ________________________________________________________

(City) (State) (Zip)

             Phone (_____) __________________________     Phone (_____) ____________________________

               (Office)                                                                                (Home)

             Email address______________________________________________________

             Do you have active status in a terminal degree program? _____Yes _____No

             If yes, please complete the following:

             Program_______________________________________________________

   (MA, PhD) (Department)

             University_________________________________ City______________________________ State____________

             Expected date of degree completion_____________________________________________________

(Month, Year)

             Please indicate your current situation:

             ___ Taking course work in a doctoral/terminal program

             ___ Have completed required course work in a doctoral/terminal program, but have not passed oral exam

             ___ Have passed oral exams and working on doctoral dissertation

             ___ Other (please explain) ____________________________________________________________________

                                            ___________________________________________________________________________

             Name of your major ________________________________ Adviser: __________________________________

             Major adviser's mailing address: _________________________________________________________________

             Major adviser's phone number: (_____) _________________________________

             Do your future plans include teaching in higher education? _____Yes _____No

             Do you have college or university teaching experience? _____Yes _____No

If yes, please describe: ____________________________________________________________________________________________________

                                          ____________________________________________________________________________________________________

                                          ____________________________________________________________________________________________________

                                          ____________________________________________________________________________________________________

                                As a teaching scholar, what course(s) for undergraduate students are you most interested in and/or best prepared to teach?

                                Most Interested                                                    Best Prepared

                    ___________________________________  ___________________________________

                     ___________________________________  ___________________________________

                      ___________________________________  ___________________________________

             Signature of Applicant: _____________________________________________________

             How did you learn about this fellowship?

             Advertisement (Source) _________________________________

             Posting (Where Posted) _________________________________

             Other (Please Specify) __________________________________

NOTE: This application must be accompanied by:

                * A cover letter and curriculum vita describing your research area(s), experience and qualifications.

                * A copy of your graduate transcript. (This can be a copy of the official transcript)

                * A letter from your major or dissertation adviser regarding your qualifications for this program.

                * A letter from at least two additional references regarding your experience and ability. (If you have teaching experience, letters should include relevant

                        information.)