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| All application materials are due to the APA Women’s Programs Office by 5 pm on May 22, 2009. |
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| 1. |
Applicant Name: |
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First Name |
Middle Initial |
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Last Name |
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| 2. |
APA Member |
Yes: Member Fellow
No |
| 3. |
Doctorate Degree
(check all that apply): |
Ph.D.
Psy.D.
Ed.D.
Other advanced degree (please specify): |
| 4. |
Number of years post doctorate: |
Early-Career (Less than 10 years post doctorate)
Mid-Career (10-20 years post doctorate)
Senior (more than 20 years post doctorate) |
| 5. |
Full time employment: |
University
College
Community College
Academic Medicine/Medical School
Research Institute |
| 6. |
Academic Rank: |
Associate Professor
Clinical Associate Professor
Professor
Clinical Professor |
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Contact Information |
| 7. |
Institution |
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| 8. |
Street |
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| 9. |
City |
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| 10. |
State/Province |
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| 11. |
Zip Code |
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| 12. |
Country |
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| 13. |
Business Telephone and Extension |
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| 14. |
Cell phone |
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| 15. |
E-mail Address |
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| 16. |
Race/Ethnicity (check all that apply): |
a. American Indian or Alaskan Native
b. Asian
c. Black or African American
d. Hispanic or Latino
e. White or Caucasian
f. Pacific Islander/Hawaiian Native
g. Other (please specify): |
| 17. |
Are you a person with a disability? |
Yes No |
| 18. |
Do you openly identify yourself as lesbian or bisexual? |
Yes No |
| 19. |
Do you openly identify yourself as transgender? |
Yes No |
| 20. |
How did you learn about APA Leadership Institute for Women in Psychology? |
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Education |
| 21. |
Colleges (list all degrees earned and graduation years) |
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| 22. |
Graduate Schools/Professional Schools (list all degrees earned and graduation years) |
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| 23. |
Internships |
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| 24. |
Fellowships and/or Post-Doctoral Training Programs |
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Employment |
| 25. |
Current Employer |
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| 26. |
Current Position(s)/Title(s): academic, clinical and/or administrative |
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| 27. |
How long have you held your current position(s)? |
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Leadership Experience
Please list the following: |
| 28. |
Leadership positions/offices held at current institution |
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| a. |
Please describe your current responsibilities and reporting relationships for your most significant leadership role. |
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| 29. |
Leadership positions/offices with former employers |
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| 30. |
Leadership positions in professional organizations |
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| 31. |
Non-governmental sector leadership positions (nonprofit, volunteer) |
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| 32. |
Public sector leadership positions held (government commission appointments, etc) |
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| 33. |
What are your leadership aspirations in your current or future professional life? |
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| 34. |
Describe one important leadership challenge you currently face or have faced. |
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| 35. |
What do you hope to gain from your participation in the APA Leadership Institute for Women in Psychology? |
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Supporting Documents
All of the following application materials are due to the APA Women's Leadership Institute in the Women's Programs Office by 5 pm on May 22, 2009.
Josephine Gyamerah
Women’s Programs Office
American Psychological Association
750 First St., NE
Washington, DC 20002
202.336.6044
202.336.6117 fax
Email
Submit the following items via email to the Women's Leadership Institute. Please put your first and last name in the subject line of the email. Also, please include your name in the filename of your attachments |
| 37. |
Please forward a Curriculum Vitae (CV). |
| 38. |
Please forward one letter of recommendation from a letter writer most relevant to your leadership aspirations (preferably from Dean or Department Chair) which addresses how the letter writer envisions your leadership roles in the next two years at your current or another professional setting. |
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