Partnership Name: Partner Information University Partner(s) Chief Executive Officer of the University Partner Name: Title: Address: Phone: Fax: Email: Dean of the College/School/Department of Education Name: Title: Address: Phone: Fax: Email: Arts and Sciences contact information for your partnership Name: Title: Address: Phone: Fax: Email: K-12 School Partner(s) K-12 School contact for your partnership (if there is more than one, include the additional name(s) in the comments section at the bottom of this form). Name: Title: Address: Phone: Fax: Email: Union/Teachers' Association Partner(s) Union/Teachers' Association contact for your partnership (if there is more than one, include the additional name(s) in the comments section at the bottom of this form). Name: Union Affiliation: (Please Type NEA or AFT) Title: Address: Phone: Fax: Email: Local Partnership Liaisons Please list three people within your local partnership who will serve as liaisons to the regional representatives and the National Office. These liaisons would be involved in the daily operations of the local partnership. Liaison 1: Name: Title: Address: Phone: Fax: Email: Liaison 2: Name: Title: Address: Phone: Fax: Email: Liaison 3: Name: Title: Address: Phone: Fax: Email: Current Holmes Scholars Information Scholar 1: Name: Title: Address: Phone: Fax: Email: Scholar 2: Name: Title: Address: Phone: Fax: Email: Scholar 3: Name: Title: Address: Phone: Fax: Email: Scholar 4: Name: Title: Address: Phone: Fax: Email: Scholar 5: Name: Title: Address: Phone: Fax: Email: Partner Contact Information Below please provide information for al of the partners affiliated with your local partnership (i.e., school districts, universities, business or community organizations, etc.). Beside each partner indicate the percentage of contribution towards the Holmes Partnership Dues. Partner Name % of Dues Contribution Contact Person Address Phone Email Other comments/concerns:
Partnership Name:
Partner Information
University Partner(s)
Chief Executive Officer of the University Partner
Name: Title: Address: Phone: Fax: Email:
Dean of the College/School/Department of Education
Arts and Sciences contact information for your partnership
K-12 School Partner(s)
K-12 School contact for your partnership (if there is more than one, include the additional name(s) in the comments section at the bottom of this form).
Union/Teachers' Association Partner(s)
Union/Teachers' Association contact for your partnership (if there is more than one, include the additional name(s) in the comments section at the bottom of this form).
Name: Union Affiliation: (Please Type NEA or AFT) Title: Address: Phone: Fax: Email:
Local Partnership Liaisons
Please list three people within your local partnership who will serve as liaisons to the regional representatives and the National Office. These liaisons would be involved in the daily operations of the local partnership.
Liaison 1:
Liaison 2:
Liaison 3:
Current Holmes Scholars Information
Scholar 1:
Scholar 2:
Scholar 3:
Scholar 4:
Scholar 5:
Partner Contact Information
Below please provide information for al of the partners affiliated with your local partnership (i.e., school districts, universities, business or community organizations, etc.). Beside each partner indicate the percentage of contribution towards the Holmes Partnership Dues.
Other comments/concerns:
