Participation Application

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Phone*
Home Phone
Work Phone
I am 45 years old or under:
I have recieved the COVID-19 Vaccine:
Email*

Current Employer*
Employer Email
Employer Phone
Employer Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Position*
Department*
Supervisor*
Duties / Responsibilities*
Upload Commitment Form, Resume, and Letter(s) of Recommendation*
Please upload the required .pdf file(s): 1. Signed commitment form 2. Your resume 3. Letter(s) of recommendation. Your application must contain these required items in order to be considered for the Ka Ipu Kukui Fellows Program.
Drop files here or

Accepted file types: pdf, doc, docx, odf, txt, rtf, Max. file size: 300 MB, Max. files: 9.

Work or Other Relevant Experience
Three most relevant work or other relevant experience. Please include, leadership positions, budgetary authority, supervisory responsibilities and number of employees supervised
Company / Employer #1*
Phone*
Position*
Start Date*
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY

Leave this blank if you are still working for this employer.
Duties/Responsibilities*
Please briefly describe your role at the company.
Company / Employer #2
Phone
Position
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY

Leave this blank if you are still working for this employer.
Duties/Responsibilities
Please briefly describe your role at the company.
Company / Employer #3
Phone
Position
Start Date
MM slash DD slash YYYY
End Date
MM slash DD slash YYYY

Leave this blank if you are still working for this employer.
Duties/Responsibilities
Please briefly describe your role at the company.

Education*
Please list all schools attended: High School, Vocational School, Undergraduate School, and Graduate School. You can add rows for additional schools by clicking on the small + symbol after your first entry.
School Years Attended Degree / Certificate Year Awarded
Interests*
Community Leadership and Contributions*
Please describe present or past volunteer community involvement - including any leadership positions, responsibilities and the dates of your involvement
Honors and Awards*
Please list all Awards, Honors and/or Offices held - including awards during your Academic, Professional and/or Community Service career

Recruitment
How did you hear about the program? Did someone refer you to the program? If so, please state the person’s name
Short Essays
Please respond to each of the following three questions. (250-word count per question)
1. What would you like to gain by your involvement in this program?*
You may write or cut-and-paste a short essay up to 250 words to answer the above question.
2. What unique qualities/talents will you bring? And why should the Board consider you as a Fellow?*
You may write or cut-and-paste a short essay up to 250 words to answer the above question.
3. In your judgment, what is the most pressing challenge facing Maui Nui today? Please give your recommendations for approaching and resolving this challenge.*
You may write or cut-and-paste a short essay up to 250 words to answer the above question.
Please remember applications must be received no later than 4:00 PM HST on July 5, 2022

Work or Other Relevant Experience

School	Years Attended	Degree / Certificate	Year Awarded