First-Time College Students
NSF S‐STEM Scholarship Program at Purdue University Calumet Scholarship Application Form Please complete this form and return with personal statement, unofficial copy of your transcript, and two
letters of recommendation (from your high school counselor and/or from teachers to):
NSF S-STEM Scholarship Program at Purdue University Calumet
c/o Ronald E. McNair Post-Baccalaureate Achievement Program
Student Union and Library Building – Room 335
Hammond, Indiana 46323-2094
219.989.2779
All application materials must be received no later than 4:30 p.m. Friday, July 28, 2011.
Name: _____________________________________________________________________________________________
Last
First
Middle
Mailing Address: _____________________________________________________________________________________
Number
Street
Apt. Number
_____________________________________________________________________________________
City
State
Zip
E-Mail Address: __________________________________________________
Telephone Number: ___________________________
Date of Birth: _______________________________ Purdue Calumet ID Number: _______________________
Gender: _______ Male
_________ Female
Grade Point Average: ________________________
High School Graduation Date: _________________ High School GPA: ______ on a _____ Scale Class Rank: _____
SAT Score - Critical Reading ______ Math: ______ Writing ________
ACT Score – Composite: ______ English ______ Mathematics ______ Reading ______ Science ______
Intended Major: ____________________________________
Ethnicity:
‰ American Indian
‰
Asian or Pacific Islander
‰
White/Non-Hispanic
‰
Other
‰
Black/Non-Hispanic
‰
Hispanic
‰
Other: ___________________________________________
U.S. Citizen: ____Yes ____ No
Permanent Resident: ____Yes ____ No
Other:__________________________ Please explain:
Personal Statement
On a separate paper describe the academic and professional goals you would like to achieve. Be as specific as
possible about research projects of particular interest to you. Be sure to include the route that you have taken to
date to reach these goals, including any adversities you have had to overcome. State how the awarding of a SSTEM Scholarship would assist you in achieving your academic and professional goals. Your Personal Statement
should not exceed three double-spaced pages.
Please provide the following information (attach additional sheets, if needed):
1.
List honors, awards, or recognition that you have received from your high school or other sources.
2.
List employment positions you have had and the dates of employment.
3.
List extracurricular and community activities you have participated in during the past three years and approximate
number of hours per month dedicated to each activity.
4.
What is the average number of hours per week you have worked during the school year?
I hereby certify to the best of my knowledge that all information submitted is complete and correct. I understand that failure to disclose accurate
information is grounds for immediate termination from this program.
Signature:
Date: