Future Faculty Fellowship Application

A King*Chavez*Parks Initiative of the state of Michigan

Applicant

First Name:   M.I.   

Last Name: 

Maiden (If applicable): 

Email: 

Birth date:  January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Driver's License #: 

SSN: 

NMU IN: 

Ethnicity: 

Street: 

City:   State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming  Zip: 

Home: 

Cell: 

Work: 

Next of Kin

First Name:   M.I.   

Last Name: 

Maiden (If applicable): 

Street: 

City:   State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming  Zip: 
 
Home: 

Cell: 

Work: 

Email: 

Adviser

Name: 

Department: 

Office Address: 

Phone:  Fax: 

Email: 

Program

Master's Program Name: 

Program Start Date:  January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Ancipated Graduation Date:  January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

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Send/Drop off all material to:

Future Faculty Fellows
Multicultural Education and Resource Center
Northern Michigan University
Marquette, MI 49855

For questions or concerns:

Office: 906-227-1554
-or-
Fax: 906-227-1740

Northern Michigan University does not unlawfully discriminate on the basis of ancestry, race, color, ethnicity, religion or creed, sex or gender, gender identity, gender expression, genetic information, national origin, age, height, weight, marital status, familial status, handicap/disability, sexual orientation, military or veteran status, or any other characteristic protected by federal or state law in employment or the provision of services. NMU provides, upon request, reasonable accommodation including auxiliary aids and services necessary to afford individuals with disabilities an equal opportunity to participate in all programs and activities.