CENTER FOR THE ART OF EAST ASIA and DEPARTMENT OF ART HISTORY UNIVERSITY OF CHICAGO

2005-2006 POSTDOCTORAL FELLOWSHIP SUPPLEMENTAL DATA FORM

APPLICANT INFORMATION

Last Name: ________________________

First Name: _____________________________ Middle Initial: ________________

Date Ph.D. completed (dd/mm/yy): __________ 

Granting Institution: ______________________

Title of Dissertation: ___________________________________________________

____________________________________________________________________

Dissertation committee members:  ________________________________________

____________________________________________________________________

Names of references with email addresses: ______________________________

____________________________________________________________________

____________________________________________________________________

Visa status (check one): U.S. Citizenship ______;  U.S. Permanent resident ______;

J-1 _____;  F-1 _____;  H-1 ______

CONTACT INFORMATION (Please notify if any changes are made)

Address: ____________________________________________________________

____________________________________________________________________

Telephone number: ________________________

Fax number: ______________________________

Email address: ____________________________

Return this form with all other application materials no later than March 15, 2005 to:

Postdoctoral Fellowship Program

Center for the Art of East Asia and Department of Art History

University of Chicago

5540 South Greenwood Avenue

Chicago IL 60637