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ApplicationsmustbepostmarkedbyFebruary1. Applicationsmailedfromoverseas 'J%  shouldbesentbyairmailorothertimelymeansasearlyaspossible.  .-*& ЇMailoneoriginalandtwocopiesofyourapplicationto:ThePresidentsCommissiononWhiteHouseFellowships712JacksonPlace,NWWashington,DC20503  , ThisapplicationmaybedownloadeddirectlyfromtheInternet,butitmaynotbesubmittedinelectronicform.Onlyhardcopypaperapplications,oneofwhichmustincludeoriginalsignatures,willbeaccepted.Applicantswillbenotifiedbymailthattheirapplicationhasbeenreceived.SeeQ.6.OnlyU.S.citizensareeligibletoapply.Civilianemployeesofthefederalgovernmentarenoteligible.TheCommissioncannotconsiderapplicationsfromineligibleapplicants,norgrantexemptionsfromtheserequirements.Thefederalgovernmentisanequalopportunityemployer.Hiringisbasedonqualificationsandperformanceregardlessofracecolor,creed,religion,sex,age,nationalorigin,sexualorientationordisability. l(&A SXX5 PartI  X X5XS 1.PERSONALDATA  R Wk XX5j5 Wk_______________________________________________ * Name(Last,First,Middle)_______________________________________________Othernamesused  AreyouaU.S.citizen?[]Yes[]No  J   _______________________________________________ Birthdate(month/day/year)_______________________________________________SocialSecurityNumber_______________________________________________Occupation/Profession ContactInformation (whereyoucanbereachedfrom 6 FebruarytoJune):_______________________________________________MailingAddress:Street_______________________________________________City,State,Zip_______________________________________________HomePhone   P  WorkPhone ^ _______________________________________________FaxNumber   P  EmailAddress "  EmploymentInformation : v$ _______________________________________________CurrentEmployersName_______________________________________________CurrentEmployersAddress:Street_______________________________________________City,State,Zip_______________________________________________YourTitle,RankorStatus -+: Haveyoueverworkedfororareyounowworkingforthefederalgovernment,orareyoubeingpaidbyfederalfunds?(Includeactivedutymilitaryservice.)[]Yes  []No @= IfYES,pleaseexplainbelowandgiveinclusivedates:_____________________________________________________________________________________________________________________________________________XHXj5X5XXXH 2.PersonalDeclarations Wk XX5j5 Wk  D Pleaseanswerthefollowingquestionsandexplainonaseparatesheetofpaperdetailsandresolutionofanyquestionanswered yes. HaveyoueverbeendischargedfromtheArmed  H Forcesunderotherthanhonorableconditions?   l I []Yes  []No , J  Haveyoueverbeenconvictedofacriminal D K offense?   L []Yes  []No lM  Haveyoueverbeenchargedwithafelony?  ,N []Yes  []No DO  Haveyoueverbeenchargedwithaviolationof P anyfirearmsorexplosiveslaws?  lQ []Yes  []No ,R  Haveyoueverfailedtomeetacourtorderedchild DS supportpayment?  T []Yes  []No lU  Areyoudelinquentonanyfederaldebt?  ,V []Yes  []No DW  Haveyoueverbeensuspended,disciplined,or X barredfromanyoccupationorpracticebyanyregulatoryagency,professionalassociationororganizationbecauseofyourconduct?  D[ []Yes  []NoXHXj5X5XXXH \  3.Certification  X^ Wk XX5j5 WkIcertifythatallofthestatementsinthisapplicationare D_ true,complete,andcorrecttothebestofmyknowledgeandbelief,andaremadeingoodfaith.______________________________________________Signature(inink)     x DateXHXj5X5XXXH !Dc  4.Investigation  H# e Wk XX5j5 WkIknowandunderstandthatanyorallitemscontained 4$!f hereinmaybereviewedbyrepresentativesoftheCommission,includingformerWhiteHouseFellows,andifIbecomeaNationalFinalist,aresubjecttoinvestigationorverificationbydulyaccreditedinvestigatorsofthefederalgovernment.______________________________________________Signature(inink)     x DateXHXj5X5XXXH t)'m Ї 5.References  X Inthespacebelow,listthenamesandcontactinformationfortheindividualswhosepersonalevaluationsaccompanythisapplication(seeQ.17).Youmaysubmitaminimumof3andamaximumof5recommendationsforconsideration.  #1   L    Wk XX5j5 Wk______________________________________________ | $  Name______________________________________________Address______________________________________________Address______________________________________________City,State,ZipXHXj5X5XXXH  #2  P   Wk XX5j5 Wk______________________________________________ ( Name______________________________________________Address______________________________________________Address______________________________________________City,State,ZipXHXj5X5XXXH  #3   T%   Wk XX5j5 Wk______________________________________________ ", ' Name______________________________________________Address______________________________________________Address______________________________________________City,State,ZipXHXj5X5XXXH -0+5 Ї  #4  X5   Wk XX5j5 Wk______________________________________________ 07 Name______________________________________________Address______________________________________________Address______________________________________________City,State,ZipXHXj5X5XXXH  X A   #5  \  C   Wk XX5j5 Wk______________________________________________ 4 E Name______________________________________________Address______________________________________________Address______________________________________________City,State,ZipXHXj5X5XXXH \O SXX5 PartII  $T X5XS 6.RequiredCards  V Thefollowingtwocardsmustbeincludedwithyourapplication:(1)Atyped3x5indexcardthatlistsononesideonlyyourname,mailingaddress,homeandworkphonenumbers,anddateofbirth.(2)Aselfaddressed,stampedpostcard.ThiscardwillbemailedtoyouasarecordthatyourapplicationhasbeenreceivedbytheCommission. .(%b SXX5 PARTIII  X X5XS INSTRUCTIONSFORQUESTIONS716 > Wk XX5j5 WkThefollowingquestionsshouldbeansweredon  separatesheetsofpaper.Typeyourname,SocialSecurityNumberandquestionnumberintheupperrightcornerofeachpage.Donotreturnorreproducethequestionswithyourapplication;submitontheanswers.XHXj5X5XXXH7.CareerSummary  n   Wk XX5j5 WkOnaseparatesheetofpaper,undertheheading Career F  Summary, pleaseprovideachronologicallistingofallthepositionsyouhaveheld,beginningwiththemostrecent.Includedates,employersand/orschoolsattended.Accountforallperiodsofunemployment.Pleaselimityourresponsetoamaximumofonepage;detailscanbefurnishedinresponsetolaterquestions.Example:11/98topresent  SeniorVP,Acme,Inc.  9/96to11/98   P SalesDirector,Acme,Inc. n Ѐ6/96to9/96   P Unemployed/JobSearch . 8/94to6/96   P MBAstudent,BigUniv. F 6/94to8/94   P ServiceProjectinPeru  9/90to6/94   P Student,SmallCollegeXHXj5X5XXXH n  8.EducationalBackground  r Wk XX5j5 WkOnaseparatesheetofpaper,typetheheading J!  EducationalBackgroundandincludethefollowinginformation:(1)Undertheheading SchoolAttendedlistallschools J % attendedincludinghighschoolwithdegreeordiplomaearned,nameofschool,location,anddatesattended.(2)Undertheheading Activitieslistallofthemajor J# ) extracurricularactivitiesinwhichyouparticipated.Brieflyexplaineachoneandlistthelevelofyourparticipation,includinganyofficesheld,andthelengthofyourmembership.Listmajorawardsorrecognitionsreceived.XHXj5X5XXXH J&#-   ~-&+5 9.WorkExperience  X5 Wk XX5j5 WkOnaseparatesheetofpapertypetheheading WorkExperienceandprovidedetailsaboutyouremploymenthistory.Workbackfromyourcurrentpositionandaccountforallperiodsofemploymentandunemployment.Donotsubstitutearesume.Youmayuseasmanysheetsof ; paperasrequired.Usethefollowingasaguide:DatesofemploymentExactjobtitleEmployerEmployersaddressandphonenumberNatureofthebusinessNumberofworkersyousupervisedForyourcurrentpositionpleaseprovideabriefnarrativedescriptiveoftheworkyouperformed,nottoexceed200words.Youmayatyouroptiondescribepreviousworkaccomplishmentsbutdonotexceed100wordsforeachdescription.XHXj5X5XXXH 10.VoluntaryActivities  0K Wk XX5j5 WkOnaseparatesheetofpaper,typetheheading Voluntary M Activitiesandlistthemajorcivicandsocialactivities(not pN relatedtoyourjob)inwhichyouhaveparticipated.Usethefollowingasaguide:NameoforganizationCityandStatePurposeorobjectiveoftheorganizationSizeoforganizationYourlevelofparticipationDatesofyourparticipationAwardsorrecognitionsyoureceivedXHXj5X5XXXH 11.ProfessionalActivities  Z Wk XX5j5 WkOnaseparatesheetofpaper,typetheheading  t\  ProfessionalActivitiesandlistthemajorbusinessand !4] professionalactivitiesinwhichyouhaveparticipated.Usethefollowingasaguide:NameoforganizationCityandStatePurposeorobjectiveoftheorganizationSizeoforganizationYourlevelofparticipationDatesofyourparticipationAwardsorrecognitionsyoureceivedXHXj5X5XXXH  )&g  INSTRUCTIONSFORQUESTIONS1216  X Wk XX5j5 Wk Pleasebeawarethatyouwillbejudgedonthe 0 clarityofyourwritingandyourabilitytofollowinstructionsaswellasonthesubstanceofyournarratives.XHXj5X5XXXHԀ  p  12.MostSignificantAchievement: H ЀProfessional  4  Wk XX5j5 WkOnaseparatesheetofpaper,typetheheading     ProfessionalAchievementandthendescribewhatyouconsidertobeyourmostsignificantcontributiontoyourprofessionalfield.Pleaselimityournarrativeto200words.XHXj5X5XXXH L   13.MostSignificantAchievement:   ЀCommunityService    Wk XX5j5 WkOnaseparatesheetofpaper,typetheheading d  CommunityServiceAchievementandthendescribewhatyouconsidertobeyourmostsignificantcontributiontoyourcommunity.Pleaselimityournarrativeto200words.XHXj5X5XXXH d  14.MemorandumforthePresident  h Wk XX5j5 WkOnaseparatesheetofpaper,typetheheading @  MemorandumforthePresidentandwriteamemorandumforthePresidentmakingaspecificpolicyproposal.Explainwhyyouthinkitisimportant,whatissuesitraises,andwhyyouthinkthePresidentshouldsupportyourproposal.Pleaselimityourmemoto500words.XHXj5X5XXXH 15.LifetimeGoals  l" Wk XX5j5 WkOnaseparatesheetofpaper,typetheheading Lifetime D $ Goalsanddescribeyourlifesambition,whatyouhopetoaccomplishorachieveinyourlifetime,andwhatpositionyouhopetoattain.Pleaselimityournarrativeto300words.XHXj5X5XXXH D# (   X*   $"*  X*  X* H 16.WhyIWanttoBeaWhiteHouseFellow  $"* HWk XX5j5 WkOnaseparatesheetofpaper,typetheheading WhyI &p$, WanttoBeaWhiteHouseFellowanddescribeyourmotivationforapplyingforthisfellowship,whatyouconsidertobeyourmajorstrengthsandqualificationsfortheprogram,andwhatbenefitsyoufeelarelikelytoresultfromyourparticipation.Pleaselimityournarrativeto300words .  . 2j5S2   -*2   -*4 PARTIV  X4 X5XS񀀀 f5  17.References  R6 Wk XX5j5 WkPleasereproducetheCandidateEvaluationformthatis *8 partofthisapplicationandgiveittoaminimumof3andamaximumof5peoplewhoknowyouwell.Recommendersshouldhaveadirectknowledgeofyourqualificationsandcharacter.Atleastoneofthemshouldhaveprofessionalcompetenceinyourfield,atleastoneshouldhaveknowledgeofyourmajorcommunityorcivicactivities,atleastoneshouldhaveknowledgeofyourbusinessorprofessionalaccomplishments,andatleastoneshouldbeyourcurrentsupervisor,ifapplicable.Eachofyourrecommendersshouldsealtheletterofreferenceinanenvelope,signhisorhernameacrosstheseal,andreturnthesealed,signedlettertoyou.Thesereferencesmustbesubmittedalongwithyourapplicationbythedeadline.Yourapplicationcannotbeconsideredwithoutthesereferences.XHXj5X5XXXHSXX5 APPLICATIONCHECKLIST X5XS .N &&XX5 []Q.3andQ.4signedininkanddated (P  P H[]OneoriginalandtwocopiesofapplicationH[]TwocardsasrequestedinQ.6[]Sealed,signedrecommendations X5X&& ,V SXX5 ForMoreInformation  "Z [ X5XSPresidentsCommissiononWhiteHouse $x"] Fellowships712JacksonPlace,NWWashington,DC2050320239545222023956179(fax)www.whitehouse.gov/WH_Fellows X*(c Ї&(xXxHH(  Wk XX5j5 WkREPRODUCETHISFORMFORREFERENCES0Wk j5g/33#` p" `EHg#j5 0WkQ#(bRNz \|`I/,#@ H@EP |3P |(bRNz \|`I/,#@ H@E|3|XHXj5X5XXXH  &XXX  &XXX  LLXX5 WhiteHouseFellowshipApplication   CandidateEvaluation   u    SLL +X5XS +To:SXX5 +    ___________________________________________________ 3  Wk Sj5 Wk    Individualcompletingevaluation2j5S2 C  X5XS +From:    ThePresidentsCommissiononWhiteHouseFellowshipsSXX5 + k X5XS +Subject:SXX5 +  ___________________________________________________ g  Wk Sj5 Wk    Applicantsname2j5S2 w  X5XS +(xXxH$H$(Wk XX5j5 WkThankyoufortakingthetimetowritearecommendation #  fortheWhiteHouseFellowshipapplicantnamedabove.YourcandidandspecificresponsestothequestionsbelowwillhelpthePresidentsCommissionselectthenextclassofWhiteHouseFellows,11to19individualsfromacrossthenationwhowillcometoWashingtontoworkforoneyearaspaid,fulltimespecialassistantstoCabinetofficersandseniorWhiteHouseofficials. 1.Howlongandinwhatconnectionhaveyou  knowntheapplicant?2.Whataretheapplicantsmajorstrengths?Pleaserelateanoccasioninwhichthesestrengthsweredemonstrated.3.Whataretheapplicantsmajorweaknesses?4.Whatimpacthastheapplicanthadonhis/herprofessionalfield?5.Whatimpacthashe/shehadinthecommunity,outsideoftheapplicantsprofessionalrealm?& X  X   6.Whathasthecandidatedonethatyouconsidercreative?  )K''  c- +, ЇPleaseanswerthefollowingquestions(onyourofficeletterhead,ifappropriate)andincludeyourdaytimetelephonenumber.Pleasesignanddateyourevaluation,placeitinasealedenvelope,writeyoursignatureovertheseal,andreturnittotheapplicant.Theapplicantmustsubmityourevaluationaspartofhisorherapplication.TheapplicationdeadlineisFebruary1. 7.Howwouldyoudescribethiscandidates #4 writingability?8.Howwouldyoudescribethiscandidatesintellectualability?9.Howwouldyoudescribethiscandidatespublicspeakingability?& X  X   10.Howwouldyoudescribethiscandidatespersonalintegrity?11.Howwouldyoudescribethiscandidatesconsensusbuilding,negotiatingandleadershipskills?12.IfyouwereaCabinetSecretary,wouldyouhirethispersontobeakeymemberofyourstaff?13.Whatdoyouexpectthiscandidatetobedoingin15to20years? XHXj5X5XXXH #+(H  +)I &XXX    *'H & X  X   (xXxHH(    PRIVACYACT   Wk XX5j5 WkThePresidentsCommissiononWhiteHouseFellowshipsoperatesitscompetitiveapplicationprocessandcollectspersonal  ` informationforevaluatingapplicationsunderauthorityofExecutiveOrder11183,asamended.Submissionoftheinformationisvoluntary;however,failuretofurnishalltherequestedinformationmayresultinadelayoreliminationfromconsiderationforafellowship.ExecutiveOrder9397authorizesustorequestyourSocialSecurityNumbertoidentifyindividualrecords.FurnishingyourSocialSecurityNumberisvoluntaryandfailuretoprovideitonthisapplicationwillnotaffecttheconsiderationofyourapplication.Theinformationyouprovide,orthatissubmittedonyourbehalf,maybedisclosedtomembersofourselectioncommittees,madeupofformerWhiteHouseFellows,individualsfromtheprivatesectororothergovernmentalagencies.Theinformationmayalsobedisclosedtoacongressionalofficeinresponsetoaninquiryfromthatofficemadeatyourrequest.XHXj5X5XXXH PAPERWORKREDUCTIONACT  d  Wk XX5j5 WkUnderthePaperworkReductionAct,nopersonmayberequiredtorespondtoacollectionofinformationunlessitdisplaysa < validOMBnumber(thisformisdesignatedwithOMBControlNo.32000032).Thisformisestimatedtotakeanaverageofeight(8)hourstocomplete,includingtimeforreviewinginstructions,gatheringtherequestedpersonalevaluations,andcompletingtheapplication.PleasesendcommentsregardingthisburdenestimateoranyotheraspectofthiscollectionofinformationtothePresidentsCommissiononWhiteHouseFellowships,Washington,DC.XHXj5X5XXXH RECORDSRETENTION   Wk XX5j5 WkTheapplicationformsofpersonsselectedasWhiteHouseFellowsmaybecirculatedtoappropriateExecutiveBranchofficials h incidenttoplacingFellowsinassignmentsforthefellowshipyearandsubsequentlymayberetained,alongwithotherapplicantfilematerials,bytheCommissioninitspermanentfilesonpersonswhoareselectedasWhiteHouseFellows.Thesepermanentrecordsareaccessibletotheindividualsconcerned.Sixtydaysafteraletterhasbeenmailedtoanapplicantadvisingthatheorshehasbeeneliminatedfromthecompetition,allmaterialsintheapplicantsfilewillbedestroyedandthisprocedurewillberepeatedaftereachstageoftheselectionprocess.TheCommissioncannotberesponsibleforthereturnofapplicationsorsupportingdocuments.Applicantsarethereforeadvisedtoretaincopiesoftheirapplicationformsandnottosubmitirreplaceabledocumentsormaterialswithapplications.2j5S2  OMBControlNo.32000032