Fellowships Permissions and Waiver Form

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This form is required for all students or alumni seeking Middlebury nomination or award in a scholarship or fellowship competition. Please review the information below carefully. Direct any questions you have to Fellowships in the CTLR at Middlebury College at fellowships@middlebury.edu.

Email *

First Name *

Last Name *

Graduation Year *

YYYY

Middlebury ID# *

Applying for a Fellowship *

I understand that it is an honor and privilege to apply for a Middlebury College nomination or award in a scholarship or fellowship competition. I acknowledge that both my personal reputation and the reputation of the College can benefit from the manner in which I represent myself and Middlebury College. I will do everything within my control to safeguard my good name and that of Middlebury College throughout this award competition. I am applying for the below fellowship or scholarship:

Beineke

Fulbright

Goldwater

Truman

Udall

UK-Irish (find list at go/uk-irish)

Vermont Law School

Waston

Other:

Required

Code of Conduct *

Because fellowship programs expect students to uphold Middlebury codes of conduct, I agree to disclose to the fellowship office any disciplinary action to which I have been subject. This information will remain confidential within the fellowship office. I understand that the fellowship advisor will discuss with me whether a violation or sanction affects my ability to be nominated by Middlebury.

Yes

I affirm that I have never been the subject of official disciplinary action for misconduct or academic offenses, or been required to withdraw from the College.

I have been the subject of official disciplinary action.

I have been required to withdraw from the College.

Misdemeanor or Felony *

Have you ever been adjudicated guilty or convicted of a misdemeanor or felony?

Yes

Misconduct Explanation

If you answered "yes" to the 2nd or 3rd question about misconduct or to the misdemeanor or felony question, please provide a brief explanation of the violation, circumstances and sanction or conviction.

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