The Education Policy and Leadership Center - Pennsylvania Education Policy Fellowship Program Application

PENNSYLVANIA EDUCATION POLICY FELLOWSHIP PROGRAM

2007-2008 Application Form

Enrollment is limited. Please apply early.

Please print and return this completed application, including signatures from both the applicant and sponsor, to:

Pennsylvania Education Policy Fellowship Program
The Education Policy and Leadership Center
800 North Third Street, Suite 408
Harrisburg, PA 17102

Applicant Information

Name of Applicant:
Professional Title:
Organization/Institution:
Business Address:
City:
State:
Zip code:
Office Phone:
Office Fax:
Home Address:
City:
State:
Zip code:
Home Phone:
E-mail:

Act 48 and SBA Credit

The EPFP has been approved to provide Act 48 credits to individuals holding Pennsylvania teaching or administrative certificates, and State Board of Accountancy (SBA) credits to certified public accountants. Participants could earn approximately 120 credit hours toward their requirement by attending all scheduled and approved activities.

Please check here if you are interested in receiving Act 48 or SBA credit and include your Social Security number.

Act 48 credit.

SBA credit.

Social Security #:

Education (Please cite most recent experience first)

University/College	Degree	Date

Work Experience (Please list current position first)

Title:
Dates Employed:
Employer's Name & Address:
City:
State:
Zip code:

Title:
Dates Employed:
Employer's Name & Address:
City:
State:
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ENDORSEMENT:

TO THE SUPERVISOR/EMPLOYING AGENCY REPRESENTATIVE
2007-2008 Pennsylvania EPFP Fellows are expected to participate in ten full-day seminars in Harrisburg and attend two national conferences that bring together Fellows from all EPFP sites. The first of these two conferences is scheduled for December 3-5, 2007, in Atlanta, Georgia, and the second is scheduled for April 9-12, 2008, in Washington, DC. The program costs, plus travel-related costs to the national conferences, are paid by the employing agency and/or the Fellow. Your signature affirms (1) your employee’s release time for full participation in the Fellowship Program and (2) payment of program-related costs, including program fee of $2,750. If you have any questions, please contact Ron Cowell at the Pennsylvania EPFP, 717-260-9900, cowell@eplc.org.

To Be Completed By Applicant

Printed Name:
Signature:
Date:

To Be Completed By Supervisor/Sponsor

Printed Name:
Signature:
Date:
Supervisor's Title:
Supervisor's Organization/Institution:
Office Address:
City:
State:
Zip code:
Office Phone:
Office Fax: