Form 5 UGSP Application

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UNDERGRADUATE SCHOLARSHIP PROGRAM
OMB No. 0925-0299
Expiration Date 08/31/2016
Respondent Burden

PROGRAM APPLICATION
Instructions: Before you begin, you may want to review some helpful hints on using this electronic form and our privacy statement.
Eligibility Criteria:

1. Candidates must be U.S. citizens or U.S. permanent residents.
2. Candidates must be enrolled or accepted for enrollment as a full-time student at an accredited 4-year undergraduate institution
located in the United States of America.

3. High school students are not eligible.
4. Candidates must have an Undergraduate University Grade Point Average of 3.3 or higher on a 4.0-point scale or within the top 5
percent of your class.

5. Candidates must have an 'Exceptional Financial Need' as certified by your undergraduate institution financial aid office
(https://www.training.nih.gov/programs/ugsp).
Application Tips:
This form allows you to save a partially completed application. To take advantage of this feature:
Enter as much information into the form as you would like. Note that you must complete certain fields--Name, E-mail Address,
Phone, etc. --in order to save a partial application.
Press "Save Partial Application & Quit" to save the information you have entered thus far. You will have to return later to complete
your application.
When you first submit your partial application, you will receive an e-mail message containing instructions for accessing the online
tool that allows you to review, modify, and complete your application.
Only completed applications are available for review by NIH investigators and administrators; partial applications are not accessible by
NIH investigators. Once you complete your application, press "Preview Completed Application." You will be taken to a page displaying
the information you have provided. To submit your completed application, you must select the "Save" button on the Preview page.
IMPORTANT NOTE: The deadline for receipt of completed applications is March 14, 2016 (11:59 p.m., Eastern Time). Applications that
are incomplete after the deadline will not receive further consideration.

1. Please read the "Undergraduate Scholarship Program page" and ""UGSP Frequently Asked Questions" before beginning your online
application.

2. Be sure that the e-mail addresses you provide for your references are accurate. Incorrect e-mail addresses will delay the processing
of your application and could result in your application's not receiving full consideration.

3. Please note that this form accepts plain text inputs only. This means that special characters and formatting such as bullets, "smart
quotes," bold or italic fonts, Greek letters, etc., will be lost or altered. To ensure your data appear as you intend, compose your

inputs to the longer fields on this form using a plain text editor (e.g., Notepad for PC users or TextEdit for Mac users). In place of
special formatting, you will need to rely on the use of capital letters, white space, asterisks, and other standard keyboard characters.

4. Proofread your application thoroughly for accuracy and completeness; false or inaccurate information may be grounds for denying
your candidacy or removing you from the program.

5. Letters of recommendation requests are submitted immediately to your references upon saving of a partial application or
submission of a complete application, whichever may be first.

6. Letters of recommendation are due no later than March 28, 2016, at 11:59 pm EDT. We will not accept letters after that time.
Indicates a required field.

Minimally Required
You must enter this information if you wish to save your application.
Name:

Mr.
Prefix

First

MI

E-mail Address:

Format: [email protected]

Permanent Home Phone:
Citizenship Status:
Current Education Level:
Year at Current Level:

Last

Format: (999) 999-9999
US Citizen
College/University (4 year)
1st

Enrollment: Are you enrolled in, or have you applied to, a 4-year college/university
program located in the U.S.?
Yes

No

Education: Have you been awarded a bachelor's or master's degree?
Yes

No

Certification of Non-Delinquent 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 certify I do not have delinquent status.
I agree

I disagree

Certification of Application - Information is True, Complete, and Accurate: 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.
I agree

I disagree

Certification of Application - Release of Information to UGSP: To ensure your eligibility requirements, the UGSP may need to
contact your academic institutions for clarification of information in your application or financial form.

I authorize the program(s) indicated in my Educational History 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.
I agree

I disagree

References - Minimally Required
You must enter this information if you wish to save your application.
Under the Family Educational Rights and Privacy Act of 1974, as amended (P.L. 93-380), you have the right to access the information
contained within a letter of recommendation unless you have waived such access. The National Institutes of Health (NIH) does not
require you to waive your permission as a condition of admission. For each reference, your response about waiving access to each
letter of recommendation is required. Your references will be given your response in the recommendation request message sent by
email. See Family Educational Rights & Privacy Act.
Reference 1:
Name:

Mr.
Prefix

First

MI

E-mail:

Last
Format: [email protected]

Waive Access:

Yes

Name:

Mr.

No

Reference 2:

Prefix

First

MI

E-mail:

Last
Format: [email protected]

Waive Access:

Yes

Name:

Mr.

No

Reference 3:

Prefix

First

E-mail:
Waive Access:

MI

Last
Format: [email protected]

Yes

No

Personal Information
Permanent Address:
Address Line 2:
City:
State:
(Use DC for District of Columbia and NA if your permanent address is not in the U.S.)

Zip/Postal Code:
Country/Region:

United States

Academic Information
You must provide a complete history of all academic courses and grades you have taken and are currently taking. Be certain to
reformat your transcript information as directed, else the admission committee will have difficulty understanding and assessing your
academic experience and strengths. Updated information about your courses and grades will not be accepted after the application
deadline.
Do you have coursework from a 2-year academic institution?
Yes

No

Are you, or do you anticipate, transferring from a 2-year program to a 4-year program this Fall?
Yes

No

College or University
This section is required if you are a student at a 4-year college/university.
College/University Name:
Start Date:
Anticipated Graduation Date:
Major Field of Study:
Current Cumulative GPA:
GPA Scale (Maximum Value):
College or University Please do NOT copy and paste your transcript.
Coursework and Grades: Click here to see how to format coursework and grades.
(Up to 15,000 characters)

Community College
This section is required if you indicated above that you have coursework from a 2-year institution.
Community College Name:
Start Date:
Anticipated Graduation Date:
Major Field of Study:
Current Cumulative GPA:
GPA Scale (Maximum Value):
Community College Please do NOT copy and paste your transcript.
Coursework and Grades: Click here to see how to format coursework and grades.

(Up to 15,000 characters)

High School
This section is required if you are a 1st-year student.
High School

Please do NOT copy and paste your transcript.

Coursework and Grades: Click here to see how to format coursework and grades.

CV/Resume Sections
Answer the following questions using the space provided. You may copy and paste plain text though reformatting may be
necessary. Be sure to make note of the character limits, which include spaces.
Please do not place hard returns at the end of each line - it is only necessary at the end of paragraphs. The open text fields
are designed to automatically wrap text.
Personal Statement: (Up to 4500 characters)

Scientific Discipline / Research Interests: (Up to 4500 characters)

Influential Person or Event: (Up to 1800 characters)
Describe an influential person or event that has impacted your educational or career aspirations.

Career Interests and Goals: (Up to 1800 characters)
What is your ultimate goal and describe your planned academic path and training to achieve it?

Awards & Honors: (Up to 3000 characters)
List and awards and honors you have received in your undergraduate career. Freshman year applicants should list awards and honors
received in high school.

Experiences and Extracurricular Activities: (Up to 3000 characters)
List any additional experiences and extracurricular activities, including volunteer experiences you participated in during college.
Freshman year applicants should included high school experiences and extracurricular activities. Include your role in each activity.

Presentations: (Up to 3000 characters)
List any STEM / health-related oral or poster presentations you have given during college. Freshman year applicants should include
high school STEM / health-related oral or poster presentations.

Additional Information: (Up to 1500 characters)

How did you hear about this program? (Please select all that apply.)
Ad in a scientific journal (Nature, Science); please specify:
Ad in a student journal; please specify:
Ad in a meeting program
Exhibit at a meeting; please specify:
Career development/opportunities workshop
Flier
Poster
From a mentor or advisor
From an alumnus/alumna of the program
NIH representative visited school
Web search

Other; please specify:

Notice to all applicants:
It is your responsibility to ensure that all of the above information is correct. False or inaccurate information contained in this
application or provided during an interview may be grounds for denying your candidacy or removing you from the program.
Failure to wait for the confirmation webpage will result in an unsuccessful upload. Please be patient.

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