Form 07 GRAD 07 GRAD Eisenhower Application

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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 2125-0617. 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)  American Indian or Alaska Native  Asian  Black or African American  Native Hawaiian or Other Pacific Islander  White ETHNICITY (optional)  Hispanic or Latino  Not Hispanic or Latino
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.

09/06

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07GRAD