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NSF-CSEMS APPLICATION FORM Erik Jonsson School of Engineering by aya20861


									                           NSF-CSEMS APPLICATION FORM
             Erik Jonsson School of Engineering and Computer Science
                 Scholarship Awards for 2008 – 2009 Academic Year
Applicants MUST submit the following documents to the Financial Aid Office, McDermott
Library (MC1.304 – Lower Level), by April 28, 2008 to be considered for this scholarship.
1. This fully-completed application form.
2. Two letters of recommendation (see Recommendation Form)
3. A one-page Personal Statement (see description below)
4. If you think you may qualify for a need-based scholarship, you MUST complete a 2008-2009
Free Application for Federal Student Aid (FAFSA) (UTD Title IV school code is 009741).

Applicant Name: ______________________________________________________________
                     First                     Middle                    Last

Applicant UTD Email address:
                                     UTD NetID
Note: Scholarship awards will be announced during the second week of the Fall 2007
semester using your official UTD email address. You must respond to this email
indicating your acceptance of the award.

Social Security Number: ______-_____-________

Your social security number (SSN) is being requested because it is a unique identification number which is maintained to
assure that the correct student record is being updated, for tracking purposes and for state and federal reporting
requirements. The disclosure of such information is voluntary. Disclosure of your social security number will be governed
by the Public Information Act (Chapter 552 of the Texas Government Code).

A) Employment History (beginning with current or most recent); continue on back of form
if required
Job Title                   Duties                       Employer                    City, State                  Dates Worked

B) List awards, honors, or memberships (ACM, SWE, etc.) ; continue on back if required

E) Personal Statement (limited to one single-spaced, typed page)
Please attach a one-page essay. Include a statement of your educational goals and career
objectives. Describe computer science or software engineering projects you have completed.
Explain how the CSEMS Program will affect your educational and career plans.

I understand that if I am offered and accept this scholarship, I must remain enrolled full-time at UTD with a CS,
SE, or CS/SE major, I must meet with a faculty advisor during each semester I am funded, and I must complete
any requested surveys or other assessment tools related to this scholarship. To the best of my knowledge, I
certify that all of the above information is correct. I understand that my signature below gives permission for the
NSF CSEMS Committee to review any academic records and any information pertaining to my eligibility for
Federal Financial Aid. I further consent to the release of such information for reporting purposes to the NSF.

APPLICANT SIGNATURE_________________________________________________DATE _______________

With few exceptions, you are entitled at your request to be informed about the information UTD collects
about you. Under Sections 552.021 & 552.023 of the TX Govt. Code, you are entitled to receive and review
the information. Under Section 559.004 of the TX Govt. Code, you are entitled to have UTD correct
information about you that is held by us and that is incorrect.

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