Form

2013-14 Iowa Space Grant Consortium (ISGC)
Scholarship and Fellowship Program

Application Deadline Extended: May 20, 2013
4:00 p.m. CST

Deadline has passed - application process is closed.

Full Name:*

First Name Last Name

E-mail Address:*

Address

Street Address
Street Address Line 2
City	State
Postal / Zip Code

Home Phone Number:

- Area Code Phone Number

Cell Phone Number:

- Area Code Phone Number

Are you a U.S. Citizen? (Citizenship required.)*

Yes No

Educational Information: What ISGC affiliate university will you be attending in August 2013?
(Make selection in drop box below.)

Iowa Space Grant Affiliate:*

Major*

Current Standing*

Overall GPA*

Minimum 3.0/4.0 GPA

Next University Graduation:*

Month

Year*

Year

Transcript Submission*

Unofficial copy will suffice. PDF file is preferred.

Transferred credits from a Community College since January 2012?

No Yes (If yes, please supply information below.)

In the text boxes below, please list the colleges and universities that you have attended. If you are currently a university freshman please include the high school name and address that you graduated from. If you are currently a high school senior, please also include the high school name and address (a transcript may be requested).

College/University/High School

Department

Credits Completed

Overall GPA

4 pt, non-weighted scale

Academic research history. (Add comments regarding research project involvement, if any, including project advisor's name and employer.)

0/250

Employment Goals: What type of employment will you seek after graduation? (250 words or less.)

0/250

Comments: (In 250 words or less, tell us why you would be a good candidate for a scholarship or fellowship, or other comments on your eligibility. Include curricular activiites, honors & societies.)

0/250

Have you previously received a Space Grant award?

Yes No

If so, please describe the project and your experience (250 words or less.)

Recommendation Letter/s: Submission of at least one recommendation letter is required (maximum of two) by a mentor or academic advisor. It is the responsibility of the applicant to ensure that the recommender submits a letter by the April 30, 2013 - 4:00 p.m. central standard time application deadline. Send an e-mail to your recommender to use the following URL for an online submission:
http://form.jotformpro.com/form/30274255464958

Within the body of the e-mail, copy and past the following text with the appropriate choice clearly stated:

"I have waived or not waived the right to read your letter. Applicants who waive their right cannot read your letter, those who have not waived their right may read the letter you submit in the ISGC office, but the ISGC will not distribute a copy."

Recommendation Letter Waiver*

I waive my right to review submitted recommendation letter/s I do not waive my right to review submitted recommendation letter/s

Please complete the following demographics questions, for NASA reporting purposes only. This information will not impact selection of awardees, and will not be released to the selection committee.

Demographics: Gender

Male Female

Do you have a documented disability?

Yes No

Race and/or Ethnicity (check all that apply):

African Amerian Asian Caucasian Hispanic or Latino Native American Pacific Islander Other

AGREEMENTS AND DECLARATIONS: Check the boxes below each question as appropriate .

I am a citizen of the United States of America.*

Yes No

I meet all of the eligibility requirements as outlined in the program announcement.*

Yes No

I understand that if selected I must enroll in an independent study course at my institution as outlined in the program announcement.*

Yes No

If selected, I agree to provide final unofficial transcripts upon graduation to the Iowa Space Grant.*

Yes No

If selected, I agree to participate in a NASA longitudinal tracking process which surveys student progress and eventual employment outcome to help assess the effectiveness of the program.*

Yes No

I am the person represented in this applcation. All of the provided information is complete and correct.*

Yes No