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UNDERGRADUATE SCHOLARSHIPS
IN SCIENCE
Nominating and Supporting Information
PLEASE READ CAREFULLY!
In order for a nominee to be considered, a complete application must be returned to the Mathematics Department, Old Gymnasium, Room 223 A, by March 15, 2011.
A complete application includes:
Completed Nominating and Supporting Information form;
Nominees Essay;
Two (2) supporting letters (sent separately).
The nominee should secure letters of recommendation from individuals knowledgeable enough about the student to assess the nominees personal characteristics, motivation, and potential for a mathematics or natural science career. The evaluations should include one from each of the following: a faculty member in the nominees field of study and an individual who can discuss the nominees potential for a career in mathematics or the natural sciences. These two supporting letters should be sent directly to the Advising Resource Center.
Affirmation of Candidacy and Authorization f o r R e l e a s e o f I n f o r m a t i o n
I , F O R M T E X T , u n d e r s t a n d t h a t I h a v e b e e n n o m i n a t e d f o r a C l a r e B o o t h e L u c e U n d e r g r a d u a t e S c h o l a r s h i p i n S c i e n c e f o r t h e 2 0 1 1 - 1 2 a c a d e m i c y e a r a n d a f f i r m m y w i s h t o b e c o n s i d e r e d . P e r m i s s i o n i s h e r e b y g i v e n t o o f f i c i a l s o f t h e n o m i n a t i n g i n s t i t u t i o n t o r e l e a s e t r a n s c r i p t s o f m y a c a d e m i c r e c o r d t o d a t e a n d o t h e r r e q u e s t e d i n f o r m a t i o n f o r c o n s i d e r a t i o n i n t h e L u c e S c h o l a r s h i p P r o g r a m .
D a t e F O R M T E X T / F O R M T E X T / F O R M T E X T S i g n a t u r e
[ P r i v a c y A c t A dvisory Statement: Pursuant to the Act (P.L. 93-579), please be advised that the authority for the collection of these data is P.L. 93-642; that furnishing this information is voluntary; that the principal purpose(s) for which this data will be used is selection of a Clare Boothe Luce Scholar; that other routine uses of the data are for public relations (press releases); that failure to complete the form will mean that you cannot be considered for designation as a Clare Boothe Luce Scholar.]
Nominees Pers o n a l D a t a ( P l e a s e p r i n t . )
L e g a l n a m e i n f u l l F O R M T E X T
L e g a l r e s i d e n c e F O R M T E X T
C a m p u s a d d r e s s ( i f d i f f e r e n t f r o m a b o v e ) F O R M T E X T
C a m p u s p h o n e n u m b e r ( F O R M T E X T ) - F O R M T E X T - F O R M T E X T D a t e o f b i r t h ( m m / d d / y y y y ) F O R M T E X T / F O R M T E X T / F O R M T E X T
E l i g i b i l i t y D a t a
A n t i c i p a t e d d a t e o f g r a d u a t i o n F O R M D R O P D O W N F O R M D R O P D O W N
W i l l y o u b e a f u l l - t i m e s t u d e n t p u r s u i n g a b a c h e l o r s d e g r e e d u r i n g t h e 2 0 1 1 - 1 2 a c a d e m i c y e a r?
FORMCHECKBOX Yes
FORMCHECKBOX No
Are you a United States citizen or a United States national?
FORMCHECKBOX Yes
FORMCHECKBOX No
Are you enrolled in an undergraduate field of study that will lead to a career in mathematics or the natural sciences?
FORMCHECKBOX Yes
FORMCHECKBOX No
Are you considering a career in Medicine?
FORMCHECKBOX Yes
FORMCHECKBOX No
Your Schooling
List, in chronological order, all schools attended in t h e l a s t f o u r y e a r s , i n c l u d i n g a n y f o r s u m m e r o r s p e c i a l c o u r s e s .
N a m e o f S c h o o l L o c a t i o n D a t e s o f a t t e n d a n c e F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T
W h a t c o u r s e o f s t u d y ( m a j o r ) a r e y o u f o l l o w i n g i n c o l l e g e ?
F O R M T E X T
W h a t i s y o u r c u m u l a t i v e G P A a s o f J a n u a r y 2 0 1 1 ? F O R M T E X T
L i st courses in your major in which you are currently enrolled, courses in your major in which you plan to enroll before graduation, and courses in mathematics and science that are outside your major in which you are currently enrolled or plan to enroll.
Courses in major
(currently enrolled)Courses in major
(plan to enroll)Math/science courses
(outside of major) FORMTEXT F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T
D o y o u p l a n t o a t t e n d g r a d u a t e o r p r o f e s s i o n a l s c h o o l a f t e r c o l l e g e ?
F O R M C H E C K B O X Y e s
F O R M C H E C K B O X N o I f y e s , w h a t i s y o u r d e g r e e o b j e c t i v e ? F O R M T E X T I n w h a t f i e l d ? F O R M T E X T
A c t i v i t i e s a n d A c h i e v e m e n t s
L i s t a c t i v i t i e s i n w h i c h y o u h ave participated in your school (such as clubs, publications, debating and dramatics, music, art and student government. Place an X in front of those activities you consider most important.
College ActivityDates ParticipatedOffices heldAwards FORMTEXT F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T
H i g h S c h o o l A c t i v i t y D a t e s P a r t i c i p a t e d O f f i c e s h e l d A w a r d s F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T 8 ` }
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H o w d o y o u f e e l t h e C l a r e B o o t h e L u c e s c h o l a r s h i p w i l l c o n t r i b u t e t o y o u r c a r e e r g o a l s ?
L e t t e r s o f R e c o m m e n d a t i o n
P l e a s e g i v e t h e n a m e s o f t w o p e o p l e w h o w i l l b e w r i t i n g l e t t e r s o f r e c o m m e n d a t i o n i n s u p p o r t o f y o u r a p p l i c a t i o n f o r a C l a r e B o o t h e L u c e U n d e r g r a d u a t e S c h o l a r s h i p . A l e t t e r s h o u l d c o m e f r o m e a c h o f t h e f o l l o w i n g : a f a c u l t y m e m b e r i n t h e n o m i n e e s f i e l d o f s t u d y a n d a n i n d i v i d u a l w h o c a n d i s c u s s t h e n o m i n e e s p o t e n t i a l f o r a c a r e e r i n m a t h e m a t i c s o r t h e n a t u r a l s c i e n c e s .
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