University of Minnesota

Upper Midwest Human Rights Fellowship
2010 Application Form


Deadline: Friday, February 12, 2010, 4:00 pm

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I. PERSONAL INFORMATION
Last Name*:First Name*:
Mailing Address:
Address1*:
Address2:
City*:
State:                        Zip:       
Country:
Permanent Address(If Any):
Address1:
Address2:
City:
State:                        Zip:       
Country:
Additional Information:
Phone1:         Type:   
Email1*:
Phone2:         Type:   
Email2:
Citizenship (If not US, indicate type of Visa) :      
Please specify your relationship to the Upper Midwest region (eg,place of birth, family, home, location of school/work, former residence,etc.)*:
If you are currently a student, please indicate type/course of study.
Under graduate       Law School       Other       If other please include   
Medical School      Graduate                               Major/Course of Study    
If you are currently employed, please complete the following Information.
Current Place of Employment Current Position
Brief Description
Lenght of time in this position
How did you learn of the Upper Midwest Human Rights Fellowship Program? (check all that apply)
  Brochure   Educator   Email Announcement   Info Session
  Past Fellow   Presentation   Website   Other
If other Please List:


II. EMERGENCY CONTACT INFORMATION
Last Name*: First Name*:
Phone1:                 Type:  Phone2:                 Type: 
Relationship to the Applicant:


III. PROPOSED FELLOWSHIP INFORMATION
Name of the Proposed Host Organization
Location of Proposed Fellowship
City:            State:            Country   
Name, title, and address of supervisor in proposed host organization
Name*: Title:
Address1: Address2:
City: State:                    Zip:       
Country:
Phone1:               Type:  Phone2:           Type: 
A. Please provide a brief description of the proposed fellowship to be undertaken with this grant. (maximum 100 words)*
B. Language study relevant to area of fellowship. Include language, years of study, practical experience, and level of fluency.*
C. Have you applied for any other financial assistance to pursue your proposed fellowship? If so, please describe.
    (This will not adversely affect the selection committee's decision)*
D. Itemized budget estimate for proposed fellowship.
Expense (US dollars)                                                           Description
Transport                              
Lodging                              
Food                              
Funding from other sources                              
Total


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