Prospective Applicant Form

First Name *

Middle Initial

Last Name *

Nickname

Pronouns

She/He/They

UR Student ID *

Email *

example@example.com

Local Phone Number *

Please select all that apply:

Transfer student International student Take5 or e5 student

Select One *

Graduation Year *

Major(s) *

Minor(s)

Cumulative GPA *

Take Five/e5 Program Topic

Certificate(s)

Program *

Degree *

PhD, MS, MA, MBA, etc.

Expected Year of Completion *

Undergraduate Degree(s) Earned *

B.A., Art History; B.S., Chemistry

Undergraduate Cumulative GPA *

Undergraduate Certificate(s) Earned

Permanent Address *

City *

Citizenship *

United States Non-US

State of Legal Residency *

Country of Citizenship *

If you are a PERMANENT RESIDENT, are you currently seeking U.S. citizenship?

Yes No

If YES, when do you expect to receive your U.S. citizenship?

Please enter month & year (e.g. May 2021 or 05/21)

FIRST RECOMMENDER: Name

FIRST RECOMMENDER: Email address

FIRST RECOMMENDER: Position / Title

e.g. Professor; Marketing Director; Department Chair; Dean of Admissions, etc.

FIRST RECOMMENDER: Department / Organization

e.g. Department of Microbiology, Johns Hopkins University; UR Physics Dept, etc.

SECOND RECOMMENDER: Name

SECOND RECOMMENDER: Email address

SECOND RECOMMENDER: Position / Title

e.g. Professor; Marketing Director; Department Chair; Dean of Admissions, etc.

SECOND RECOMMENDER: Department / Organization

e.g. Department of Microbiology, Johns Hopkins University; UR Physics Dept, etc.

THIRD RECOMMENDER: Name

THIRD RECOMMENDER: Email address

THIRD RECOMMENDER: Position / Title

e.g. Professor; Marketing Director; Department Chair; Dean of Admissions, etc.

THIRD RECOMMENDER: Department / Organization

e.g. Department of Microbiology, Johns Hopkins University; UR Physics Dept, etc.

FOURTH RECOMMENDER: Name

FOURTH RECOMMENDER: Email address

FOURTH RECOMMENDER: Position / Title

e.g. Professor; Marketing Director; Department Chair; Dean of Admissions, etc.

FOURTH RECOMMENDER: Department / Organization

e.g. Department of Microbiology, Johns Hopkins University; UR Physics Dept, etc.

If you have already identified any award(s) you'd like to discuss, please indicate them here. You may choose multiple options from the list below:

RÉSUMÉ *

Upload your resume or C.V. here; .pdf ONLY

By my signature below, I acknowledge my understanding that both my personal reputation and the reputation of the University of Rochester can benefit from the manner in which I represent myself. I therefore affirm my wish to be considered for formal nomination or endorsement by UR for a national student fellowship or award.

To that end I hereby grant the following permissions and waivers, with the understanding that the purpose of this release is for the University of Rochester to consider my application or nomination for a merit-based national scholarship or fellowship.

1. I waive my right to view recommendation, nomination, or endorsement letters written for the purpose of the fellowship competition. While the authors may provide copies of these letters to me, I understand that this is a courtesy by the author and does not affect this waiver.

2. As required under the Family Educational Rights and Privacy Act, commonly known as FERPA, I give permission for my grade point average (GPA), transcripts, individual course grades, and individual assignment grades to be used and discussed as a part of the award competition. I give permission for the Fellowships Office of the University of Rochester to request official and unofficial copies of my transcript(s) as part of the application process.

3. I grant my consent to the Fellowships Office of the University of Rochester to check my official college records for any violations of either the University’s academic or conduct policies.

a. I waive my rights of confidentiality in my Board on Academic Honesty records and authorize the Board to report to the Fellowships Office any record of violations for which I have been found responsible.

b. I waive my rights of confidentiality in regards to any UR conduct offense violations and authorize the Fellowships Office to obtain a copy of any disciplinary report(s) from the Office of the Dean of Students. The ODOS may also provide contextual information as to the severity of those offenses.

4. I consent to the Fellowships Office sharing selected information about my fellowship/scholarship application for the purpose of publicity, especially as to any success I may have in the competition.

5. I agree to notify the Fellowships Office if I withdraw from competition.

OPTIONAL: I understand that by checking this box, I agree that the Fellowships Office may also use an anonymized version of my application essay(s) for the purpose of training other applicants. *

I agree I do not agree

Signature: I acknowledge that I have read this form, understand it, and agree to be bound by its terms. I further acknowledge that I sign this agreement voluntarily and I am at least eighteen years of age. I understand that this consent will remain in effect until either 1) the end of the current academic year, 2) through the end of the award competition, if later, or 3) it is revoked by me in writing.

Clear

I understand that my next step is to call the Fellowships Office for an appointment: 585-276-5869 *

YES

Prospective Applicant Form

Recommenders

Awards of Interest

Résumé & Waiver Form

Please read the following carefully.