UNC General Administration Learning Differences Programme

Oak Foundation Fellowship Program Application

Section I. Biographical Information

Name: □Mr. □ Ms. □ Mrs. □ Dr.□ Miss

lastfirstmiddle (jr.,sr.,etc.)

Former Name:(another names that may appear on educational records)

Date of Birth: Sex: □ Male □Female

mo day year

Citizenship Status: □US citizen □Non-US citizen Country of citizenship

Section II. Address/Contact Information

Primary Phone:( ) Mobile Phone ( ) Work Phone( )

Email Address:

Permanent Address:

number & street, P.O. box, apt. #, etc.

______

city state zip country

Mailing Address:

number & street, PO box, apt. #, etc.

______

city state zip country

Section III. Graduate Program of Study

Educational Policy__Education Leadership ______Science of Learning/Neurobiology______

Instructional Technology______Curriculum & Instruction ______Public Admin./Policy______

Non-Profit Management ______Other ______

Section IV. Recommendation Letters (list the names/addresses of individuals who will submit recommendations supporting your application)

1. ______

2, ______

3. ______

Section V. Academic History(post-graduate/graduate/undergraduate)(list most recent first)

Name of College/University / City, State / Dates of Attendance / Degree and Date Awarded / Major / Overall GPA

Section VI. Employment Experience(list most recent first and add additional sheets if necessary)

Employer, City, State / Dates of Employment / Job Title / Reason for Leaving

Section VII. Awards, Publications, Memberships other Skills(attach additional sheets if necessary)

Honors, Awards, Scholarships Received:

Publications, Presentations:

Memberships and Leadership/Research Experiences:

Foreign languages and fluency:

UNC General Administration Learning Differences Programme

Section VIII. Related Experience/ActivitiesRelevant to Professional Goals (attach additional sheets if necessary)

agency/address/phone number from (mo/yr) to (mo/yr) type of activity

agency/address/phone number from (mo/yr) to (mo/yr) type of activity

agency/address/phone number from (mo/yr) to (mo/yr) type of activity

Section IX. Statement of Interest and Professional Goals (attach your Statement to the last page of this application form and include your full name at the top for identification purposes)

On no more than two pages, (typed double spaced, at least 10-12 pt. font, 1 inch margins) please indicate your interest in the area of Learning Differences in the K-20 setting, how this interest aligns with your professional goals and the skills/strengths you will bring to the Learning Differences Programme team..

Section XI. Honor Statement

I hereby certify that the information provided here is complete and accurate. I understand that falsifying or withholding information in completing this application constitutes grounds for immediate withdrawal of my application from further consideration, cancellation of admission, or registration.

Applicant’s Signature: ______Date: ______

unsigned applications will be returned

Letter of Recommendation Form

Section I To be completed by applicant

Applicant’s Name: ______

Applicant’s signature Date

Address (required) to which letter is to be sent:

Section II To be completed by recommender

Please provide your candid evaluation of this applicant’s ability to successfully complete a term as an Oak Foundation Fellow in the Learning Differences Programme. Attach additional pages if necessary.

On the following scale, please indicate the rank of this applicant against other students or employees who you have known in comparable fields.

top 2% / top 10% / top 25% / top 50% / no basis for judgment

Recommender’s Name: Position or title:

Institution: Telephone:

Address:

Signature: Date:

Letter of Recommendation Form

Section I To be completed by applicant

Applicant’s Name: ______

Applicant’s signature Date

Address (required) to which letter is to be sent:

Section II To be completed by recommender

Please provide your candid evaluation of this applicant’s ability to successfully complete a term as an Oak Foundation Fellow in the Learning Differences Programme. Attach additional pages if necessary.

On the following scale, please indicate the rank of this applicant against other students or employees who you have known in comparable fields.

top 2% / top 10% / top 25% / top 50% / no basis for judgment

Recommender’s Name: Position or title:

Institution: Telephone:

Address:

Signature: Date:

Letter of Recommendation Form

Section I To be completed by applicant

Applicant’s Name: ______

Applicant’s signature Date

Address (required) to which letter is to be sent:

Section II To be completed by recommender

Please provide your candid evaluation of this applicant’s ability to successfully complete a term as an Oak Foundation Fellow in the Learning Differences Programme. Attach additional pages if necessary.

On the following scale, please indicate the rank of this applicant against other students or employees who you have known in comparable fields.

top 2% / top 10% / top 25% / top 50% / no basis for judgment

Recommender’s Name: Position or title:

Institution: Telephone:

Address:

Signature: Date:

Application Coversheet and Checklist

Applicant Name ______

Please use the checklist below to insure that your application is complete.

Your application must include:

This Coversheet and Checklist

Cover Letter

Completed Oak Foundation Fellowship Program application form – all pages, additional sheets if needed, and certifying signature

The Statement of Interest and Professional Goals

A current resume

Three sealed letters of recommendation using the forms provided

Official transcripts from all colleges and universities attended

Applications must be mailed in a single envelope and postmarked no later than February 15, 2013. Mail your completed application to:

Oak Foundation Fellowship Program

University of North Carolina General Administration

C/O Betsy Rich

910 Raleigh Road

Chapel Hill, North Carolina, 27514