Dwight David Eisenhower Transportation Program

Dwight David Eisenhower Transportation Fellowship Program

Eisenhower_Application2a

Dwight David Eisenhower Transportation Program

OMB: 2125-0617

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DWIGHT DAVID EISENHOWER TRANSPORTATION FELLOWSHIP PROGRAM

2007 EISENHOWER GRADUATE TRANSPORTATION FELLOWSHIP

This collection of information is voluntary and will be used to determine the applicant’s qualifications for the DDETFP. Public reporting burden is estimated to average three hours per response, including the time for reviewing instructions and completing the application. All information collected is confidential and will be used by program staff for program administration purposes only. Please note that an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this collection is 2125-XXXX. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Highway Administration, 1200 New Jersey Avenue, SE, Washington, DC 20590.

Application Form - Part 1

Must be typed


Name (Last, First, MI)

Current Address



Telephone No.:


E-mail Address:


Alt. Number:

Permanent Address




Alt. Telephone No.:




Check the box of the degree you are seeking:


Masters Degree Doctorate Degree


Year of Study __________


Current Grade Point Average ___________

RACE (optional)

Native American

Alaska Native (Aleut or Eskimo)

Asian

African American

Native Hawaiian/Other Pacific Islander

White

Other


ETHNICITY (optional)

Hispanic or Latino

Not Hispanic or Latino

Hispanic or Latino in Puerto Rico

Not Hispanic or Latino in Puerto Rico

Date of Birth



__ __ __ __ __ __

M M D D Y Y

Gender:



Male Female

U.S. Citizen


Yes No If no, please attach a certified copy of your I-20 or I-551 ID issued by the I.N.S.



College or University (Current or Pending)

Academic Dept.



Name, Title and Address of Faculty Advisor


Telephone No.:



E-mail Address:


Applicant’s Major

Applicant’s Field of Study

Date


Signature of Applicant (Required)

Date


Signature of Faculty Advisor (Required)





DWIGHT DAVID EISENHOWER TRANSPORTATION FELLOWSHIP PROGRAM

2007 EISENHOWER GRADUATE TRANSPORTATION FELLOWSHIPS

Application Form - Part 2

Must be typed


Colleges/Universities

Attended

Dates

Attended

Degrees

Earned

Date

Awarded














Employer (most recent first)

Address

Name of Supervisor

and Telephone No.

Dates of Employment






From:



To:






From:



To:


List Academic Honors, Scholarships, Offices Held in Student /Professional Organizations, etc.





Community Activities/Organizations:


Experience in Transportation Education Programs

ENO Fellow Year


UTC Award Year

University Transportation Centers


DDE Fellowship Year

Dwight David Eisenhower Transportation Fellowship


STIPDG Year

Summer Transportation Intern Program for Diverse Groups


NSTI Year

National Summer Transportation Institute


Other Year


Name ____________________________



PRIVACY ACT STATEMENT


The information is required under the authority of the Privacy Act of 1974, as amended and Title 49 U.S.C. 332(b)(3)(4)(5). Your request cannot be processed unless the data below is complete. Disclosure of your race and ethnicity are optional. Refusal to furnish your race and/or ethnicity will not result in the denial of any right, benefit or privilege provided by law. Records maintained in the system are routinely used to determine eligibility/qualifications for fellowships, and for program evaluation and analysis purposes.



DWIGHT DAVID EISENHOWER TRANSPORTATION FELLOWSHIP PROGRAM

2007 EISENHOWER GRADUATE TRANSPORTATION FELLOWSHIPS

Application Form - Part 3

Must be typed



Proposed Plan of Graduate Study


Please provide a summary of how your plan of study will impact and enhance the field of transportation and what role transportation takes in your professional goals. Incorporate educational, personal and work experiences, accomplishments, volunteer activities and/or events that support your plan of study. Limit 2 pages.







































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Last Modified ByFHWA
File Modified2007-06-07
File Created2007-06-07

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