ࡱ> e Bbjbjhihi ^ i i  3338k<3:V;1GGG  P9999999<?9i @"  9GGb9:1#1#1# FGG91# 91#1#68GdXI r79O:0:76S@ S@,880S@8  1#     99"   :    S@         Y :  Application for Admission Cohort 20 Name:  FORMTEXT      Home Address:  FORMTEXT        FORMTEXT       Home Phone:  FORMTEXT       Business Address:  FORMTEXT        FORMTEXT       E-mail:  FORMTEXT       Preferred Mailing Address:  FORMCHECKBOX  Home  FORMCHECKBOX  Business Preferred means of contacting you:  FORMCHECKBOX  E-Mail  FORMCHECKBOX  Other _____________ Is there anyone else (i.e. your assistant) who should be included on all correspondence? If so please specify name and email  FORMTEXT      ________________________________________________________________________ Birthdate: FORMTEXT       Gender:  FORMCHECKBOX  Male  FORMCHECKBOX  Female  FORMCHECKBOX  Non-Binary Citizenship:  FORMCHECKBOX  U.S.  FORMCHECKBOX  Other _______________________________ Ethnic Background:  FORMCHECKBOX  African-American/Black  FORMCHECKBOX  Hispanic/Latino (Optional)  FORMCHECKBOX  Asian/Pacific Islander  FORMCHECKBOX  Native American  FORMCHECKBOX  Caucasian/White  FORMCHECKBOX  Multi-Racial  FORMCHECKBOX  Other ___________________ MWU/CCOM Affiliation (please specify):  FORMTEXT       II. Professional Information: Please attach a copy of your curriculum vitae. III. Interest in the Costin Institute Please answer the following questions. You may attach a separate sheet with your responses. Why are you interested in becoming a Costin cohort member?  FORMTEXT       What are your goals for the program? What are the skills or topics you are most interested in learning?  FORMTEXT       What kind of position in academe do you anticipate securing upon your completion of the Costin program?  FORMTEXT       Is there anything else you would like the Admission Committee to know about you?  FORMTEXT       IV. Letters of Recommendation: Please submit two letters of recommendation. 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Please submit letters to: Costin Institute CI Application CCOM/MWU 555 31st Street Downers Grove, IL 60515 - or - E-mail to:  HYPERLINK "mailto:costin@midwestern.edu" costin@midwestern.edu  Application for the Costin Institute Instruction Sheet (Keep for your records) Hand-written applications will not be accepted. The following items are required for a completed application to the Costin Institute: Completed Application form (which includes): Demographic information A copy of your C.V. Answers to the questions listed under  Professional Commitment Two letters of recommendation Important Dates: Deadline: TBD Costin Institute Dates for Cohort 20: TBD Questions: Call: 630-515-6159 E-mail:  HYPERLINK "mailto:costin@midwestern.edu" costin@midwestern.edu Web:  HYPERLINK "http://www.costininstitute.org" www.costininstitute.org Hand-written applications will not be accepted.     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