3 Application 2

NIH Undergraduate Scholarship Program for Individuals from
Disadvantaged Backgrounds
APPLICATION CHECKLIST
Please use this checklist to make sure all parts of your application are completed. This checklist must be
submitted with your application to:
National Institutes of Health
Undergraduate Scholarship Program
2 Center Drive, Room 2E20 (MSC 0230)
Bethesda, Maryland 20892-0230
Applicant’s Name: _____________________________________________________________________
Address: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Daytime Telephone: ____________________________________________________________________
E-mail: ______________________________________________________________________________





Official transcript (high school and college transcript required for college freshmen).
Letter of acceptance (for those entering college or transferring for the 2008–2009 academic year).
Applicant information form.
Undergraduate institution certification form. The applicant should fill out Section A. The form was
given to the following representative of the undergraduate institution:
Name and Title: ____________________________________________________________________
____________________________________________________________________
Telephone: ________________________________________________________________________
Date: _____________________________________________________________________________
 Applicant recommendation forms. The applicant should fill out Section A of each form. The
following persons have been asked to submit recommendations:
1. Name: ________________________________________________________________________
Institution: _____________________________________________________________________
Telephone: _____________________________________________________________________
Date: _________________________________________________________________________
2. Name: ________________________________________________________________________
Institution: _____________________________________________________________________
Telephone: _____________________________________________________________________
Date: _________________________________________________________________________
3. Name: ________________________________________________________________________
Institution: _____________________________________________________________________
Telephone: _____________________________________________________________________
Date: _________________________________________________________________________
 Contract

1

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

U.S. Department of Health and Human Services
National Institutes of Health

NIH Undergraduate Scholarship Program

Applicant Information
1. Applicant’s Name (Last, first, middle)

Applicant’s Instructions
Please complete all sections of this form, and return it with your signed
contract (NIH 2762-4) in the large white prepaid envelope. Do not fold
application or contract. See reverse for detailed instructions.
 Send this application package to the National Institutes of Health
Undergraduate Scholarship Program, 2 Center Drive, Room 2E20
(MSC 0230), Bethesda, Maryland 20892-0230. If you have any questions,
please call 888-352-3001 or e-mail .
2. Telephone Numbers (include area codes)
Daytime (
) __________ ______________________
Evening (

3. Mailing Addresses
Current
Line 1
Line 2
City
State
Country
E-mail

Address (until June 2008):
________________________________________________
________________________________________________
________________________________________________
________________________________________________
_________________________ ZIP Code ____________
________________________________________________

) __________

______________________

4. Social Security Number (We collect your Social Security Number
(SSN) to verify your identity, to determine your eligibility for the
Undergraduate Scholarship Program, and to keep track of the federal funds
you receive. We also use your SSN for servicing purposes under the
Undergraduate Scholarship Program. We also use this information to
determine the amount of that assistance. See Privacy Act Information in
this package.)
____________ - ________ - ____________

Permanent Address (after June 2008, if different from above):
Line 1
________________________________________________
Line 2
________________________________________________
City
________________________________________________
State
________________________________________________
Country _________________________ ZIP Code ____________
E-mail
________________________________________________

5. Citizenship
Are you a: U.S. citizen

6. College/University Enrollment
Are you currently enrolled full-time or accepted for full-time enrollment in
an accredited post-secondary institution?  Yes
 No

6c. What will your grade level in college be at the beginning of the 2008–
2009 academic year (September 2008)?
 Freshman

6a. Name of College/University (If you have applied to post-secondary
institutions but have not yet been accepted, please list the school you plan
to attend)
________________________________________________
 Enrolled
 Accepted for Enrollment

 Yes

 No

 Yes

 No

or a qualified non-citizen*  Yes
(*See note on back page.)

 No

or a U.S. national

If not a U.S. citizen, give country of citizenship and your immigration/
citizenship status:_____________________________________________

 Sophomore
 Junior
 Senior
 Other (please explain)

6b. Address
________________________________________________
________________________________________________
________________________________________________
7. Certification of Nondelinquent Status
The Federal Debt Collection Procedures Act of 1990 precludes a debtor who has a Federal judgment lien against his/her property arising from a Federal
debt from receiving Federal funds until the judgment is paid in full or otherwise satisfied. Applicants of the NIH Undergraduate Scholarship Program must
certify that they do not have a judgment lien against their property arising from a debt to the United States.
I hereby certify that I [do ] [do not ] have a judgment lien against my property arising from a debt to the United States.
I hereby certify that I [am ] [am not ] delinquent on any debt to the United States.
8. Certification
I certify that information given in this application (including any personal statements) is true, complete, and accurate to the best of my knowledge and does
not omit any material fact which would render the statement false, fictitious, or fraudulent as a result of the omission. I understand that the information given
may be investigated and that any false representation is sufficient cause for rejection of this application, or, if awarded scholarship benefits, that I am liable
for return of all awarded funds and, further, that any false statement may be punishable as a felony under U.S. Code, Title 18, Section 1001. I am aware
that any false, fraudulent, or fictitious statement may, in addition to other remedies available to the Government, subject me to civil penalties under the
Program Fraud Civil Remedies Act of 1986.
Signature (Sign your full name in ink).

Date

 __________________________________________________________________________________________________________________________
I authorize the program(s) indicated in Section 6 to release information about my academic, financial, service, and any other pertinent information to
administrators of the NIH Undergraduate Scholarship Program (UGSP) and to other authorized Government officials. This release is valid for six months
after completion of all UGSP requirements.
Signature (Sign your full name in ink).

Date

 __________________________________________________________________________________________________________________________
NIH 2762-1
PAGE 1 (FRONT)
Revised 08/07

Public reporting for this collection of information is estimated to average 3 hours and 10 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct
or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0438). Do not return the completed form to this address.

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

NIH Undergraduate Scholarship Program

Applicant Information (continued)
This application can be completed on-line at www.ugsp.nih.gov. Please provide a response to each section in the space provided or on a
separate sheet. In either case, you must use a typewriter/word processor. If you use a separate sheet, the type size must be 12-point and your response
may not exceed 300 words per question. Responses that do not follow these guidelines will not be considered.
9. What person or event has been most influential in the development of your science career? (You should describe a person or situation that propelled
you toward your career path in science or research.)

10. Discuss your specific interest in pursuing a career in biomedical, behavioral or social science health-related research and your academic and career
goals. Describe how the UGSP would help you to attain your goals, including the non-financial benefits you may attain from the UGSP and NIH.

11. In responding to the following questions be sure to only include those activities and awards that are relevant to your interest in
science and biomedical research.
a. Describe extracurricular activities in which you have participated in the past or are participating in currently. (For example—science fairs, science
clubs, internships, community service, hobbies.) Describe the specific role you played in the activities.

b . List special recognitions, scholastic awards and honors, and any scholarships you have received. Include a short narrative to help us understand
the award, scholarship, or recognition.

c. Describe any activities, whether voluntary or paid positions, that demonstrate involvement with and/or commitment to biomedical, behavioral or
social science health-related research which you participated in during the school year or summer. If you engaged in research, describe the specific
role you played in the research project.

NIH 2762-1
PAGE 1 (BACK)
Revised 08/07

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

NIH Undergraduate Scholarship Program

Applicant Information (continued)
12. How would you evaluate and describe your aptitude in relation to the characteristics listed below? In responding, give specific examples of sciencerelated projects which demonstrate your aptitude in the following areas. Avoid responses “I am very curious” or “I have much initiative.” Carefully evaluate
and include specific and relevant examples.
a

Initiative

b. Work habits

c. Curiosity

d. Creativity in problem-solving

e. Ability to work as a member of a team

f.

Leadership skills (Include elected or other positions you have held or projects you have initiated.)

NIH 2762-1
PAGE 2 (FRONT)
Revised 08/07

OMB No. 0925-0438
Form approved for use through xx/xx/xxxx

NIH Undergraduate Scholarship Program

Applicant Information (continued)
INSTRUCTIONS FOR APPLICANT INFORMATION FORM NIH 2762-1
Official Transcript
You must request that your academic institution send one official transcript, which
includes the school’s seal or official stamp, to the UGSP. The transcript should be sent to
the National Institutes of Health Undergraduate Scholarship Program, 2 Center Drive,
Room 2E20, (MSC 0230), Bethesda, Maryland 20892-0230. You are responsible for
verifying the receipt of your transcript in our office. You may do so by sending us e-mail at
. We cannot respond to telephone inquiries.
Contract (Form NIH 2762-4)
Please review this document carefully. By signing the contract you are agreeing to serve
at the NIH, and if you change your mind once you have accepted a scholarship you may
incur substantial penalties. We suggest you review the contract with your guidance
counselor, financial aid advisor, and/or parents/guardians.
Citizenship (Number 5 on Form NIH 2762-1)
If you are not a U.S. citizen or national, we urge you to carefully review the citizenship
requirements at www.ugsp.nih.gov/citizenship.htm or contact our office before
applying. Even if you are eligible to work in the United States, you may not be eligible for
this program. If you are a permanent resident, for example, your eligibility depends on
your country of citizenship.
Certification (Number 8 on Form NIH 2762-1)
Your application cannot be considered unless this Certification is signed and dated.
Please read it carefully.
Questions 9–12 (Form NIH 2762-1)
Your answers to the questions must be typed. Please limit your answers to the space
provided or follow the guidelines that precede question 9. Responses which exceed the
space limitation or do not follow the guidelines will not be considered.
This application can be completed electronically at www.ugsp.nih.gov.

NIH 2762-1
PAGE 2 (BACK)
Revised 08/07