WHITE HOUSE FELLOWSHIP APPLICATION [This section entirely replaces old application] OMB Control No. 3200-0032 Instructions Type all responses. Answer all questions fully and accurately, and sign and date the application in the space provided in Question 4. Questions 1-4 should be answered on the first two pages of the application. (These pages may be recreated on a word processor, however, the format must remain exactly the same.) Note to Internet users who download this application: Part I should be downloaded and completed such that it occupies two 8-1/2" x 11" pages. Be sure to carefully follow the directions for Question 5: it is your receipt. The remaining questions should be answered on separate sheets of plain white 8-1/2"x11" paper. Each sheet should include your name, social security number, and the question number in the upper right corner. You may include additional items with your application, such as publications featuring or authored by you, books you have written, or music you have recorded. Use your best judgment. Generally, unpublished academic papers and copies of award certificates are not helpful. Applications must be postmarked by December 1. It is the responsibility of the applicant to ensure a package mailed on December 1 is postmarked with that date. Applications mailed from overseas should be sent by air mail as early as possible. Mail applications to: The President's Commission on White House Fellowships, 712 Jackson Place, NW, Washington, DC 20503. While applications may be downloaded electronically from the Internet, they may not be filed by e-mail. Only hard-copy paper applications with original signatures will be accepted. Applicants will be notified by mail that their application has been received. Only US citizens are eligible to apply. Civilian employees of the federal government are not eligible. The Commission cannot consider applications from ineligible applicants, nor grant exemptions from these requirements. The federal government is an equal opportunity employer. Hiring is based on qualifications and performance regardless of race, color, creed, religion, sex, age, national origin, sexual orientation or disability. Application checklist First 2 pages of the application (Questions 1-4) _____ Cards requested in Question 5 _____ Lists and essays (Questions 6-15) _____ Sealed recommendations (Question 16) _____ PART I 1. Personal Data Name (last, first, middle) Birthdate (mo/day/yr) Mr. Mrs. Ms. Other Other names used Are you a US citizen: Social Security Number Yes No Occupation: (Profession, student, self-employed, retired, etc.) Current employer's name and address: Your title, rank, or status: Home address: Mailing address where you wish to receive Commission mailings, if different from above: Home phone: Work phone: Fax number: E-mail address: Have you ever worked for or are you now working for the federal government, or are you being paid by federal funds? (Include active duty military service.) If so, please explain below and give inclusive dates. Yes No Explanation: 2. Personal Declarations Please answer the following questions and explain on a separate sheet of paper details and resolution of any question answered "yes." Have you ever been discharged from the Armed Forces under other than honorable conditions? Yes No Have you ever been convicted of a criminal offense? Yes No Have you ever been charged with a felony? Yes No Have you ever been charged with a violation of any firearms or explosives laws? Yes No Have you ever failed to meet a court-ordered child support payment? Yes No Are you delinquent on any federal debt? Yes No Have you ever been suspended, disciplined, or barred from any occupation or practice by any regulatory agency, professional association or organization because of your conduct? Yes No 3. References In the space below, list the names and contact information for the individuals whose personal evaluations accompany this application (see Question 14). You may submit a minimum of 3 and a maximum of 5 recommendations for consideration. Name Address Phone 1. 2. 3. 4. 5. 4. Certification I certify that all of the statements made in this application are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I know and understand that any or all items contained herein may be reviewed by representatives of the Commission, including former White House Fellows, and are subject to investigation or verification and I consent to the full release of all information concerning my capacity and fitness by employers, educational institutions (who are authorized to release my academic records), law enforcement agencies, and other individuals and agencies to duly accredited investigators of the federal government or the Commission for that purpose. Signature (in ink) Date PART II 5. Required Cards The following must be included with your application or it will not be considered: a typed 3"x5" index card that lists on one side your name, address, home and work phone numbers, date of birth, and date of our application; and a self-addressed, stamped postcard. This card will be mailed to you as a receipt upon its arrival in the Commission office. PART III Instructions The following questions should be answered on separate sheets of paper. Type your name, social security number and question number in the upper right corner of each page. Do not return or reproduce the questions with your application; submit only your answers. 6. Career Summary It is helpful for the Commissioners evaluating your application to see "at a glance" the development of education and career patterns. Therefore, on a separate sheet of paper under the heading, "Career Summary," please provide a chronological listing of all positions you have held, beginning with the most recent. Include dates, employers and/or schools attended. Account for all periods of unemployment. Please limit your response to a maximum of one page; details can be furnished in response to later questions. Example: 6/92-present Sr. Vice President, Acme Pictures 9/90-9/92 Director of Sales, Acme Pictures 6/90-9/90 Unemployed - job search 8/89-6/90 MBA student, Enormous State University 8/86-6/89 College student, Small State College 7. Educational Background On a separate sheet of paper, type the heading "Educational Background" and include the following. Generally, answers to this question should not exceed one page. A. Under the heading, "Schools Attended," list all schools attended, including high school. List the degree or diploma earned, the name of each school, its location, dates attended and class rank. Example: MBA, Enormous State University, Anytown, USA, 8/89-8/90, top quarter. BS, engineering, Small State College, Anothertown, USA, 8/86-8/89, school does not rank students. B. If appropriate, under the heading, "Tests and Exams," list all tests and examinations required of you in order to qualify for the practice of any occupation or profession. For each test or examination, list each time you took the test, the administering agency, the state or jurisdiction and year of such exam. For each test, also indicate whether or not you passed or failed. C. Under the heading, "Activities," list all of the major extracurricular activities in which you participated. Briefly explain each one and list the level of your participation, including any offices held, the length of your membership and the level of your participation. Also list any major awards or recognitions received. 8. Work Experience On a separate sheet of paper, type the heading "Work Experience" and list information about your employment history. Work back from your current position and account for all periods of employment and unemployment. Do not substitute a resume. You may use as many sheets as required. Use the following as a guide: Dates of employment Exact job title Employer Employer's address and phone number Nature of the business Salary history Number of workers you supervised For each entry you may, at your option, provide a brief narrative description of the work you performed, not to exceed 200 words for your current position and 100 words for all previous positions. Describe any outstanding contributions made by you and list any citations, awards, or unusual promotions. Example: 6/92-present Sr. Vice President Acme Pictures, Inc. 1234 C Street, Anytown, USA 54321. (202) 555-1212 Videotape distributor Paid $70,000/yr on 6/92; currently earn $80,000/year Supervise 19 employees 9. Voluntary Community Service Activities On a separate sheet of paper, type the heading "Voluntary Community Service Activities" and list the major community service activities in which you have participated during the past ten years. Use the following guide: Name of organization City and state Purpose or objective of the organization Size of organization Your level of participation Dates of your participation Awards or recognition you received for participation Example: The Generic Good Will Association of America Headquarters: Washington, DC Group of anonymous professionals who perform significant good deeds in times of crisis 350; mostly on East Coast Founder, past president; current board member 1984-present National Service Award, 1985; Citizen of the Year Award, 1988 10. Professional and Occupational Activities On a separate sheet of paper, type the heading, "Professional and Occupational Activities" and list the major business and professional activities in which you have participated during the past ten years. Use the following guide: Name of organization City and state Purpose or objective of the organization Size of organization Your level of participation Dates of your participation Awards or recognition you received for participation Example: The Generic Business Get-Together Group Washington, DC Professional advancement of business; lobbies Congress 2,000 nationwide Co-founder; current vice president 8/93-present No awards 11. Most Significant Achievement - Professional On a separate sheet of paper, type the heading, "Professional Achievement" and then describe in 200 words or fewer what you consider to be your most significant contribution to your professional field. If you exceed 200 words your application will be disqualified. 12. Most Significant Achievement - Community Service On a separate sheet of paper, type the heading, "Community Service Achievement" and then describe in 200 words or fewer what you consider to be your most significant voluntary contribution to your community. If you exceed 200 words your application will be disqualified. 13. Memorandum for the President On a separate sheet of paper, type the heading, "Memorandum for the President" and write a memorandum of not more than 500 words for the President, making a specific policy proposal. Explain why you think it is important, what issues it raises, and why you think the President should support it. If you exceed 500 words your application will be disqualified. 14. Lifetime Goals On a separate sheet of paper, type the heading "Lifetime Goals" and describe in 300 words or fewer your life's ambition, what you hope to accomplish or achieve in your lifetime, and what position you hope to attain. If you exceed 300 words your application will be disqualified. 15. Why I Want to be a White House Fellow On a separate sheet of paper, type the heading, "Why I Want to be a White House Fellow" and describe in 300 words or fewer why you want to be a White House Fellow, what you consider to be your major strengths and qualifications for the program, and what benefits you feel are likely to result from your participation. If you exceed 300 words your application will be disqualified. PART IV 16. References Please reproduce the enclosed personal evaluation letter and give it to a minimum of 3 and a maximum of 5 people who know you well. Recommenders should have a direct knowledge of your qualifications and character. At least one person listed should have professional competence in your field, at least one should have knowledge of your major community or civic activities, at least one should have knowledge of your business or professional accomplishments, and at least one should be your present supervisor, if applicable. Each reference should seal the letter of recommendation in an envelope, sign his or her name across the seal, and return the form to you. These references must be included in your application. Your application cannot be considered without these references. WHITE HOUSE FELLOWSHIP APPLICATION CANDIDATE EVALUATION To: Individuals Completing an Evaluation Subject: (Applicant's name) From: The President's Commission on White House Fellowships Thank you for taking the time to write a recommendation for the White House Fellowship applicant named above. Your candid and specific responses to the questions below will help the President's Commission select the next class of Fellows, 11 to 19 individuals from across the nation who will come to Washington to work for one year as paid, full-time special assistants to Cabinet officers and senior White House officials. Please answer the following questions (on your office letterhead, if appropriate) and include your daytime telephone number. Please sign your evaluation, place it in a sealed envelope, write your signature over the seal, and return it to the applicant. The applicant must submit your evaluation as part of his or her application. 1. How long and in what connection have you known the applicant? 2. What are the applicant's major strengths? Please relate an occasion in which these strengths were demonstrated. 3. What are the applicant's major weaknesses? 4. What impact has the applicant had on his/her professional field? 5. What impact has he/she had in the community, outside the applicant's professional realm? 6. What has the candidate done that you consider creative? 7. How would you describe this candidate's writing ability? 8. How would you describe this candidate's intellectual ability? 9. How would you describe this candidate's public speaking ability? 10. How would you describe this candidate's personal integrity? 11. How would you describe this candidate's consensus-building, negotiating and leadership skills? 12. If you were a Cabinet Secretary, would you hire this person to be a key member of your staff? 13. What would you expect this candidate to be doing in 15 to 20 years? PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENT Pursuant to the Freedom of Information Act (5 U.S.C. 552, as amended) and the Privacy Act (5 U.S.C. 552a), the President's Commission on White House Fellowships operates its competitive application process and collects personal information for its use in evaluating applicants under authority of Executive Order 11183, as amended. Submission of the information is voluntary; however, failure to furnish all the requested information may result in delay or elimination of consideration for a Fellowship. All files, records, and other material submitted by or in behalf of any applicant, or collected or obtained with regard to an applicant, are used by those persons associated with the Commission for the purpose of screening and evaluating applications. The information may also be disclosed to a congressional office in response to an inquiry from that office made at the request of that individual. Executive Order 9397 provides for the collection of Social Security Numbers to identify individual records. Furnishing your Social Security Number is voluntary; however, failure to do so may delay the processing of your application. This request is in accordance with the clearance requirements of the Paperwork Reduction Act (44 U.S.C. 3507). The information is being collected in order to evaluate your qualifications for a Fellowship. Your response is required to make this determination. Public reporting burden for this collection of information is estimated to average five (5) hours per response, including time for reviewing instructions, gathering the requested personal evaluations, and completing the application. Please send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the President's Commission on White House Fellowships, Washington, DC 20415. RECORDS RETENTION The application forms of persons selected as White House Fellows may be circulated to appropriate Executive Branch officials incident to placing Fellows in assignments for the Fellowship year and subsequently may be retained, along with other applicant file materials, by the Commission in its permanent files on persons who are selected as White House Fellows. These permanent records are accessible to the individuals concerned. Sixty days after a letter has been mailed to an applicant advising that he or she has been eliminated from the competition, all materials in the applicant's file will be destroyed and this procedure will be repeated after each stage of the selection process. The Commission cannot assume responsibility for the return of applications or supporting documents. Applicants are therefore advised to retain copies of their application forms and not to submit irreplaceable documents or other materials with applications.