Please fill in a valid value for all required fields
Please ensure all values are in a proper format.
Are you sure you want to leave this form and resume later?
You must upload one of the following file types for the selected field:
There was an error displaying the form. Please copy and paste the embed code again.
Apply Discount
You saved
with code
Submit Form
Submitting
Name
*
Name
First Name
*
Last Name
*
Email
*
Date of Birth
*
Date of Birth
https://www.formstack.com/forms/images/2/calendar.png
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Gender
*
Gender
Male
Female
Multiple Nationalities?
*
Multiple Nationalities?
Yes
No
Nationality
Nationalities
1. Describe the world as it is.
1. Describe the world as it is.
*
Number of characters remaining:
1500
(A description of the status quo and context in which you will be working)
2. What change do you want to make?
2. What change do you want to make?
*
Number of characters remaining:
1500
(A description of what you want to change about the status quo, in the world, your personal vision for this area)
3) What do you want to explore?
3) What do you want to explore?
*
Number of characters remaining:
1500
(Describe the innovations or questions you would like to explore during the fellowship year)
4) What are you going to do to get there?
4) What are you going to do to get there?
*
Number of characters remaining:
1500
(A description of what you actually plan to do during the year)
5) Does your idea/project have a name?
*
Yes
No
Project/Idea Name
6) Have you started implementation of the idea?
*
Yes
No
If so, please provide details on organisational structure, life cycle and progress.
Number of characters remaining:
1500
7) How have you funded your initiative in the past? Please provide details of your selection in the space below.
*
Self funded
Family and friends
Not funded yet
Angel investor
Venture capital
Other
Other Funding
Number of characters remaining:
1500
8) Who are your current or potential key partners?
*
8) Who are your current or potential key partners?
9) Do you intend to implement the idea as a for profit or not for profit initiative in the future?
*
For profit
Not for profit
Haven't thought about it...
10) Where will you be based during the fellowship?
Base Country
*
Base City
*
11) Where will you implement your idea?
*
Same as above
Online
Other country or city
Project Country
Project City
12) Do you have an online presence?
*
Yes
No
Please Provide Links to your Web Presence/s
13) Does the idea/project have an online presence?
*
Yes
No
Please Provide Links to your Project/Idea's Web Presence/s
14) How did you hear about the Shuttleworth Foundation Fellowship Programme?
*
Friend
Current/Past Fellow
On the web
In the mainstream media
At a conference
Other
15) Have you applied for a Shuttleworth Foundation Fellowship in a previous round?
*
Yes
No
Upload Resume
*
File uploads may not work on some mobile devices.
Video URL
*
Previous
←
Next
→