ࡱ> UWT -bjbjVV |R<<-nn<(;======DJ==R;;P]"'h0,0!0!j0!S==.0!n w: Last Name First Name The Rosalynn Fellowships for Mental Health Journalism Applicant Profile Name: Last First Middle Preferred Address: Street City StateZipHome Phone: Office Phone:Cell Phone:Email Address: Web Site: (if applicable)Current Employer/Position: Media: Years of Professional Journalism Experience: How did you hear about this program: Proposed Issue/Topic: Summary of Statement of Interest/Purpose of Proposed Project: Previous Awards/Fellowships: Recommendation 1 from: Name: Title:Organization:Recommendation 2 from: Name: Title:Organization:Letter of Support from: Name:Title:Organization:  (For US applicants only) Application deadline: Monday, April 16, 2012. Materials postmarked after the deadline will not be accepted. Last Name First Name  The Rosalynn Fellowships for Mental Health Journalism Fellowship Application I verify that all information provided is accurate and complete. I understand that giving false or misleading information would make my application invalid. ____________________________________________________________________ Applicant Signature Date (If submitted electronically, no signature is necessary) Completed Application Packet Should Include: ____1. Profile: Email form to  HYPERLINK "mailto:ccmhp@emory.edu" ccmhp@emory.edu or send with application packet. ___ 2. Resume: List representative publications; membership in professional organizations; major journalism prizes and/or awards and year awarded. ____3. Objectives for Fellowship and Project Description: In an informal essay, not to exceed 1000 words: describe reasons for applying and how this fellowship can benefit existing work; clearly outline the proposed project and a plan for carrying it out; discuss the significance and timeliness of the topic, potential obstacles that may be encountered, and feasibility of the project; describe the expected audience reach and potential impact; and, most importantly, describe how the proposal will help reduce stigma. ____4. Samples of Professional Work: Submit up to three examples of your work. At least one of the samples should be in the media form proposed. Articles should be in original format published and electronic news reports should be airchecks. Do not submit an item that cannot be replaced. Materials cannot be returned. ____5. Letters of Recommendation*: Provide letters from two people familiar with your work, commenting on your abilities and potential as a journalist. ____6. Letter of Support*: Submit one letter from your organization's publisher, editor, producer, manager, or director, supporting the application. If self-employed, the third letter must come from an individual familiar with your work. * Letters may be included with the application packet or mailed directly to the Mental Health Program. Letters must be originals: signed and printed on original letterhead. Letters cannot be faxed or emailed. Send materials to: Rebecca G. Palpant, M.S. 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