Undergraduate Scholarships Program Application Form

OMB Control #0648-XXXX
Expires: XX-XX-20XX

Undergraduate Scholarship Programs Application
Application for students who will be JUNIORS in the Fall term 2008

Program of Interest. Please enter [X] in the checkbox next to the program you are applying for. The website for
each program is listed for reference.
Ernest F. Hollings Undergraduate Scholarship Program; Application Due: Feb. 08, 2008
http://www.oesd.noaa.gov/Hollings_info.html
Education Partnership Program Undergraduate Scholars Program; Application Due: Jan. 31, 2008
http://epp.noaa.gov/undergrad_scholar/welcome.html

GENERAL INFORMATION
1.

Last Name:

2.

Citizenship: (Only U.S. citizens are eligible for this program).

First Name:

Middle Initial:

Yes, I am a U.S. citizen
3.

Academic Status Eligibility
Yes, I will be an undergraduate with junior class status in the Fall term 2008
Field of Study: (See attached list).
Computer Engineering

Degree:

Graduation Date:

Cumulative GPA:

GPA in Field of Study:

PAPERWORK REDUCTION ACT INFORMATION
NOAA conducts the Office of Education, Educational Partnership Program, Undergraduate Scholarship Program in order to promote the education and training
of students in NOAA sciences. The information contained in this application will be used to select undergraduate students. The information on this form will
not be treated confidentially. Public reporting burden for this collection of information is estimated to average 8 hours per application including the time for
reviewing the instructions and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing the burden, to NOAA Office of Education, Educational Partnership Program, 1315 East-West
Highway, Silver Spring, MD 20910.
Notwithstanding any other provision of the law, no person is required to respond to, nor shall any person be subject to a penalty for failure to comply with, a
collection of information subject to the requirements of the Paperwork Reduction Act, unless that collection of information displays a currently valid OMB
Control Number.

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4.

Current Contact Information
Street Address:
City:

Apt#/Unit:
State:

Phone Number:

Zip:
Alternate Number (Cell):

E-Mail:

5.

Enter [X] here if the same as above.

Permanent Contact Information
Street Address:
City:

Apt#/Unit:
State:

Phone Number:

Zip:
Alternate Number (Cell):

E-Mail:

6.

Health Insurance (required for summer internship appointments)
Company Name:

Effective Date:

EDUCATION INFORMATION
7.

Number of college course hours you have completed:
Semester Hours:

8.

Quarter Hours:

School you now attend: (Remember to have a transcript sent from this school).
Name of School:
City:

State:

Zip:

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9.

Other colleges and universities you have attended. List any other technical schools, colleges, or
universities you have attended. (Remember to have a transcript sent from each school).
Name of College or
University

10.

Location of School
(City/State)

Dates Attended
(mm/yyyy)
From
To

Degree or Certificate
Earned

List any research experiences in which you may have been involved. (Exclude class laboratory activities).
Position

Dates Attended (mm/yyyy)
From

Description

To

ACADEMIC AWARDS, HONORS, AND ACTIVITIES
11. Awards/Honors. (List honor societies, scholarship and/or fellowship awards, and other recognition).

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Extracurricular Activities. (List school-related service organizations, technical societies, and campus
activities, including offices held).

NON-ACADEMIC WORK AND VOLUNTEER ACTIVITIES
13.

List paid or volunteer activities, include the name or type of organization, the dates (months/years)
during which you worked or volunteered, and a description of what you did.

REFERENCES
14.

List two references. (Both should be from academics; one must be your advisor or department head in your
major field of study).
Name:

Title:

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E-Mail:

15.

Statement of proposed college education plan. Please concisely describe your education plan and goals (a
list of courses alone is not sufficient). We are especially interested in understanding how your education plan
is related to the NOAA mission and objectives, which may be found at http://www.noaa.gov/. Finally, include
any graduate school plans. (Please limit your response to a minimum of one page).

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Statement of career interest. Please concisely explain how you think your career interests, talents, and
initiatives are related to the NOAA mission and objectives (http://www.noaa.gov). Indicate which of the
NOAA organizations you would prefer to intern in and why. (Please limit your response to a minimum
of one page).
NOAA organization of interest:

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CERTIFICATION OF ACCURACY OF INFORMATION PROVIDED
I am aware that this program is supported by funding from the United States Government and, therefore, is subject to Federal law
regarding false statements and fraud, particularly the criminal provisions of 18 U.S. Code Section 1001. I certify, under penalty of
law, that the submitted student application contains no false or fraudulent representations, statements, or entries. An individual
receiving a scholarship under this program shall be required to repay the full amount of the scholarship to the National Oceanic and
Atmospheric Administration if it is determined that the individual, in obtaining or using the scholarship, engaged in fraudulent
conduct or failed to comply with any term or condition of the scholarship.
The information requested on the application materials will be used in connection with the selection of qualified applicants and may
be disclosed to qualified reviewers and staff assistants as part of the review process; to the institution the applicant is attending or is
planning to attend or is employed by for the purpose of facilitating review or award decisions, or administering the awards; to
government contractors, experts, volunteers and researchers and educators as necessary to complete assigned work; to other
government agencies needing data regarding applicants or as part of the review process, or in order to coordinate programs; and to
another Federal agency, court or party in a court or Federal administrative proceeding if the government is a party. Information
from this system may be merged with other computer files to carry out statistical studies, the results of which do not identify
individuals. Disclosure may be made of awardees’ names, home institutions, and fields of study for public information purposes.
Submission of the information is voluntary; however, failure to provide full and complete information may reduce the possibility of
your receiving an award.
Under certain circumstances (such as an internship at a Government-funded facility), the U.S. Government conducts background
investigations to establish that individuals are eligible for a required security clearance. The background investigations for national
security positions are conducted to develop information to show whether you are reliable, trustworthy, of good conduct and
character, and loyal to the United States. In addition to filling out a form (such as the Standard Form 86 which may be viewed at:
http://www.opm.gov/forms/html/sf.asp), inquiries also may be made about a person’s adherence to security requirements, honesty
and integrity, vulnerability to exploitation or coercion, falsification, misrepresentation, and any other behavior, activities, or
associations that tend to show the person is not reliable, trustworthy, or loyal.
NOTE: Application will be copied and used solely for the purpose of selecting scholarship recipients and administering the
Undergraduate Scholarship Program. Disclosure of the information is subject to Public Law 93-579 (Privacy Act of 1974) and
NOAA regulations.

Enter [X] in the checkbox to indicate: Yes, I have read the above information and certify as to the
accuracy of the information in my application.

Signature:

Date Certified (mm/dd/yyyy):
EPP undergraduate application, transcripts, and completed reference forms must received by January
31, 2008 electronically at [email protected] or by U.S. mail at:

NOAA/EPP Undergraduate Scholarship Program
ORISE, MS 36
P.O. Box 117
Oak Ridge, TN 37831-0117

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Fields of Study
Mathematics
Applied Mathematics
Mathematics
Probability and Statistics

Biological Sciences
Biochemistry and Biophysics
Biology
Botany
Cell and Molecular Biology
Ecology
Marine and Aquatic Sciences
Microbiology
Toxicology
Zoology

Physical Sciences
Atmospheric Science and Meteorology
Chemistry
Earth Science
Environmental Science Studies
Geology
Hydrology
Oceanography
Physics

Computer and Information Sciences
Computer Science
Computer Systems Analysis
Information Technology

Social and Behavioral Sciences
Anthropology and archeology
Economics
Geography
Geometrics
International Affairs and Policy
Political Science and Government
Science Policy/Science and Society
Sociology

Engineering
Bioengineering
Chemical Engineering
Civil Engineering
Computer Engineering
Systems Engineering
Electrical Engineering
Electronics Engineering
Communications Engineering
Mechanical Engineering
Environmental Engineering
Geophysical Engineering
Remote Sensing Technology

Teacher Education
High School Science Teacher Education
Middle School Science Teacher Education
Elementary School Science Teacher Education

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