4 Weinstein jams international Fellowship Program Application Form

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Weinstein JAMS International
Fellowship Program 
 
Application Form 
 
 
Name: _____________________________________________________________ 
 
Current Mailing Address: _______________________________________________ 
 
Permanent Mailing Address: ____________________________________________ 
 
Primary E-mail Address:________________________________________________ 
 
Alternate E-mail Address(es): ___________________________________________ 
 
Office/Work Phone: ___________________________________________________ 
 
Mobile Phone: ________________________________________________________ 
 
Date of Birth:_________________________________________________________ 
 
Nationality/Country of Origin: ___________________________________________ 
 
Current Country of Residence: ___________________________________________ 
 
Current Occupation: ___________________________________________________ 
 
Current Employer: ___________________________________________________ 
 
 
 
 

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Organizations or institutions with which you are currently affiliated in your home
country and the nature of your affiliation (eg. member, officer, director, faculty): 
 
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