LIWP 2010 Application Form
All application materials are due to the APA Women's Programs Office by 5 pm on March 1, 2010.

1. Applicant Name:
First Name    Middle Initial

Last Name

2. APA Fellow: Yes    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 (this program is for women 10-20 years post doctorate):
5. Full time paid faculty appointment at: University
College
Community College
Academic Medicine/Medical School

6. Academic Rank: Associate Professor
Clinical Associate Professor
Professor
Clinical Professor


Contact Information
7. Institution:

8. Street:

9. City:

10. State/Province:

11. Zip Code:

12. Country:

13. Business Telephone and Extension:

14. Cell phone:

15. E-mail Address:


Demographic Information
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. Pacific Islander/Hawaiian Native
f. White or Caucasian
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?



Education

21.

Colleges (list all degrees earned and graduation years):



22.

Graduate Schools/
Professional Schools
(list all degrees earned and graduation years):




23.

Internships:



24.

Fellowships and/or Post-Doctoral Training Programs:



Employment

25.

Current Employer:



26.

Current Position(s)/Title(s): academic, clinical and/or administrative (list each with dates).



Leadership Experience
Please list the following:

27.

If different from those listed in #26, list leadership positions/offices held at your current institution (with dates).



28.

For your most significant current leadership role describe your responsibilities and reporting relationships.



29.

Leadership positions/offices with former employers (with dates).



30.

Leadership positions in professional organizations (with dates).



31.

Non-governmental sector leadership positions (nonprofit, volunteer) (list with dates).



32.

Public sector leadership positions held (government commission appointments, etc) (list with dates).



33.

What are your leadership aspirations in your current or future professional life?



34.

Describe one important leadership challenge you currently face or have faced recently.



35.

What do you hope to gain from your participation in the APA Leadership Institute for Women in Psychology?



Supporting Documents
The following application materials are due to the APA Women’s Programs Office by 5 pm on March 1, 2010.

Shari Miles-Cohen, PhD
Womens 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
1. This application.
2. Your C.V.
3. One letter of recommendation from a person most familiar with your leadership aspirations and potential (preferably from a Dean or your Department Chair) which addresses how s/he envisions your leadership role(s) in the next two years.