The 2008 Mesa Refuge Application Form

Name:____________________________________________________________________

Organization:______________________________________________________________

Primary Address: _________________________________________________________

City/State/Zip: _____________________________________________________________

Work Phone:__________________________ Home Phone:________________________

Cell Phone: ___________________________ Fax: ________________________________

Email: ____________________________________________________________________

Race / Ethnicity (optional):___________________________________________________

Desired Dates of Residence

Select two- or four-week residency dates using the consecutive two-week periods listed below. Residents are selected independent of date preferences. While every effort is made to accommodate desired session dates, your first and second session choices may not be available. Four-week residencies cannot be guaranteed and are contingent on space availability; you may be offered a two-week stay instead.


Late Summer/Fall 2008 (Applications Due May 20, 2008)

Session 11: August 22nd-September 4th
Session 12: September 5th-18th
Session 13: September 19th-October 2nd
Session 14: October 3rd-16th
Session 15: October 17th-30th
Session 16: October 31st-November 13th



First Choice: Session #_________ (From to )

Second Choice: Session #_________ (From to )

Please list any additional available or preferred dates:
______________________________________________________________________

Applicant Questions

1. Have you stayed at the Mesa Refuge previously, or at other artist/writer residency programs? If so, give name and dates.

2. Do you have any special health concerns or physical disability for which you will need special assistance during your residency?

3. Do you have any special working needs?

4. Where did you learn about the Mesa Refuge?

5. For international applicants: have you spent time in the United States? If so, please describe.

Please see application instructions for all required attachments. Send one copy of your application by email to: This e-mail address is being protected from spambots, you need JavaScript enabled to view it , and send five (5) print copies by mail to:

The Mesa Refuge c/o
Common Counsel Foundation
678 13th Street, Suite 100
Oakland, CA 94612 USA
tel: (510) 834-2995
fax: (510) 834-2998