Please make sure you have read the Application Process before filling out the application.
1. Identification:
Name:_____________________________________________________
First Middle Last
Address:
________________________________________
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Office Phone:__________________________
Residence Phone:_______________________
Email Address__________________________
Fax Number:____________________________
2. Employment address:
_______________________________________
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3. Present position/title:____________________________________
4. Current teaching responsibilities:
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5. University where currently enrolled:
____________________________________________________________
Department:_________________________________________________
6. Doctoral Program and field:
____________________________________________________________
7. Title of doctoral dissertation:
____________________________________________________________
8. Proposed major field of teaching:
____________________________________________________________
9. Dartmouth College Department or Program in which you would want to be based (see list of departments and programs offering undergraduate majors or concentrations):
____________________________________________________________
10. References: Each referee you select should be familiar with your academic experience and ability and with your dissertation proposal. Each should address your qualifications and interests both as a researcher and as a college teacher. One of these referees should be the dissertation advisor. Please list references below. Please submit all letters of reference with your complete application packet to:
The Dissertation Fellowship Committee
6062 Wentworth Hall, Rm. 304
Dartmouth College
Hanover, NH 03755-3526.
1.___________________________________________
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2.___________________________________________
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3.___________________________________________
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11. Personal data:
Date of birth:_______________________________
(mo.) (day) (yr)
Social Security Number:_______________________
Place of birth:_______________________________
Citizenship:__________________________________
Optional Information:
(please check all that apply)
African American, Black___ Pacific Islander___
Asian American___ Puerto Rican___
Asian, including Indian Subcontinent___ White or Caucasian___
Latina/o American___ Other (specify)_________________
Native American___ if checked, tribal affiliation_________________________
Signature_________________________________________________________________
Date__________________________________
Application Deadline: February 1, 2010.
For a PDF version of this application, click here.
