ADA FOUNDATION PREDOCTORAL DENTAL
211 East Chicago Avenue, Suite 2100 Chicago, Illinois 60611-2678 (312) 440-2544 E-mail: [email protected] ADA FOUNDATION PREDOCTORAL DENTAL STUDENT SCHOLARSHIP PROGRAM GUIDELINES 1. Predoctoral Dental Student Scholarship Program a. ADAF Underrepresented Minority Dental Student Scholarships b. ADAF Dental Student Scholarships c. Robert J. Sullivan Scholarships d. Dr. Robert B. Dewhirst Scholarships Purpose, Description, and Objectives: The ADA Foundation (“ADAF”) Predoctoral Dental Student Scholarship Program assists dental students in financing their professional education. The scholarships are available to all dental students enrolled in accredited U.S. dental schools. The ADAF Underrepresented Minority Dental Student Scholarships assist African-American, Hispanic, and American Indian/Alaska Native dental students. Robert J. Sullivan Scholarships may be awarded to up to two students selected from the Predoctoral Dental Student Scholarship Program pool of applicants. Up to two Dr. Robert B. Dewhirst Scholarships are also awarded to students from the same applicant pool, one to an applicant from the University of California at Los Angeles School of Dentistry and one to an applicant from the Herman Ostrow School of Dentistry of the University of Southern California (USC). Dollar Amount and Number of Scholarships Available: Underrepresented Minority Dental Student Scholarships Dental Student Scholarships Robert J. Sullivan Scholarships Dr. Robert B. Dewhirst Scholarships Total
At least 25 awards
$2,500 each
Up to $62,500 total funding
At least 25 awards Up to two awards Up to two awards Up to 54
$2,500 each $2,500 each $2,500 each
Up to $62,500 total funding Up to $5,000 total Up to $5,000 total Up to $135,000 total funding
Eligibility Criteria: In order to be eligible for consideration for these scholarships, an applicant must: Be enrolled in the second year of study at the time of application, in a U.S. accredited dental school; Be enrolled as a full-time student; Demonstrate a minimum financial need of $2,500; Have a minimum accumulative grade point average of 3.25 based on a 4.0 scale; and Submit two completed reference forms and letters of reference, at least one of which letters must be submitted by one of the following: Associate/Assistant Dean/Director of Student Services, Associate/Assistant Dean of Financial Aid, Associate Assistant Dean of Academic Affairs or appropriate designee of the School of Dentistry. In the case of ADAF Underrepresented Minority Dental Student Scholarships applicants, must be a member of one of the following minority groups underrepresented in dental school enrollment: African American, Hispanic, or Native American/Alaska Native. In the case of applicants for the Dr. Robert B. Dewhirst scholarships, must be enrolled at the University of California at Los Angeles School of Dentistry or the Herman Ostrow School of Dentistry of the University of Southern California USC.
Scholarship Timetable: Scholarship Application Available: Applications due to ADAF: Notification of scholarship awards:
September 7, 2015 November 13, 2015 January, 2016
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Evaluation of Applications: Scholarship decisions and award amounts are in the sole discretion of the ADAF Board of Directors. Scholarship applications are evaluated based on a 40 point scale as follows, with 40 points being the highest possible score and 0 being the lowest score: Academic Achievement: Financial Needs Assessment: Reference Forms: Biographical Sketch:
maximum of 10 points maximum of 10 points maximum of 10 points maximum of 10 points
Scholarship Agreement: Each scholarship recipient will be required to sign a Scholarship Agreement indicating consent to the terms of the award and confirming that all information submitted is accurate. Application Submission and Review Processes: Dental school faculty and staff members are encouraged to notify students of the availability of the Scholarships using appropriate resources and technology. The application form is attached to these guidelines and are also available at www.adafoundation.org. Each accredited dental school may submit the following number of applications to the ADAF Dental Student Scholarship Program each year: o A limit of five per school for the ADAF Underrepresented Minority Dental Student Scholarships, and o A limit of one per school for the ADAF Dental Student Scholarships. o Each dental school is encouraged to submit at least one candidate for each scholarship. The recipients of the Robert J. Sullivan Scholarships and Dr. Robert B. Dewhirst Scholarships will be selected from among submitted applications (Dewhirst scholarships are limited to the schools noted). Incomplete or late applications will not receive consideration. If confirmation of receipt of the submitted application is required, please arrange to receive confirmation from the shipping vendor or U.S. Post Office. The ADA Foundation cannot confirm receipt of applications. Students who are awarded scholarships and their school officials will be notified of the award by ADAF staff. A list of scholarship winners will be posted on the ADA Foundation’s website (www.adafoundation.org) by the end of January. Applicants not selected for a scholarship will not appear on the list. Policy Statements: The ADAF does not discriminate on the basis of race, color, gender, sexual orientation, age, religion, political affiliation, national or ethnic origin, or disability. The scholarship programs are competitive, and submitting an application does not confer the right to receive a scholarship, nor ensure that an applicant will receive a scholarship. Additional Information: If you have any questions or need additional information, please contact Tracey Schilligo, ADA Foundation Grants Program Manager, at 312.440.2763 or [email protected]. The ADAF regularly updates its website, www.adafoundation.org. Please check the website for the most current program information.
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211 East Chicago Avenue, Suite 2100 Chicago, Illinois 60611-2678 (312) 440-2763 E-mail: [email protected]
ADA FOUNDATION DENTAL STUDENT SCHOLARSHIP and UNDERREPRESENTED MINOIRTY DENTAL STUDENT SCHOLARSHIP APPLICATION Deadline: Application must be received by November 13, 2015 Thank you for your interest in the ADA Foundation (“ADAF”) Dental Student Scholarship. INSTRUCTIONS: This application is an MS Word document. Please open and save it to your computer. The application must be typed in this Word document. An official dental school representative is responsible for submitting the application. The ADAF must receive all application materials in its office no later than November 13, 2015, by close of business. Due to the inclusion of sealed reference letters, applications must be submitted in paper format (via U.S. Mail, FedEx, UPS, etc.). Incomplete or late applications will not receive a response or consideration. If you require confirmation of receipt of your application, please request that confirmation with your shipping vendor or U.S. Post Office. The ADAF does not confirm receipt of applications. Mail to: ADA Foundation Attn: Scholarship Program 211 East Chicago Avenue, Suite 2100 Chicago, IL 60611-2637
ELIGIBILITY: To be eligible for this scholarship, the applicant must be a U.S. citizen and currently enrolled as a full-time student in his or her second year of study in an accredited dental degree program at the time of application. Applicants for the Underrepresented Minority Dental Student Scholarship Program must be a member of one of the following minority groups: African American, Hispanic, or Native American/Alaska Native.
AWARD: The maximum annual award for the ADAF Dental Student Scholarship is $2,500, and should be used for education based expenses.
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A.
GENERAL INFORMATION
Name: Last
First
Middle
Current Address: Number and Street City
State
ZIP
Permanent Address: Number and Street City
State
Current Telephone:
ZIP
Email : Yes ______
U.S. Citizen:
No ______
______Dental Student Scholarship
OR
______ Underrepresented Minority Dental Student
I am Applying For: Scholarship
Underrepresented Minority Dental Student Scholarship applicants only,
____ African American
please indicate:
____Native American/Alaska Native
School of Dentistry in which you are enrolled: School: Street Address: City/State/ZIP Telephone:
Please provide the name and email address for the following: Associate / Assistant Dean of Student Affairs or
Email:
Academic Affairs Name and title
Financial Aid Officer:
Email: Name and title
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____Hispanic
B.
VERIFICATION OF ACADEMIC ACHIEVEMENT RECORD (To be completed and signed by a School Official)
_________________________________________________________________________________________________________ (Type Student’s Complete Name) The student named in Section A is applying for the ADA Foundation Dental Student Scholarship. In order to consider this student’s application, it is necessary to have the Academic Achievement Record confirmed. The student must have a minimum cumulative program grade point average of 3.25 based on a 4.0 scale.* Cumulative GPA*/Class Rank**:
GPA:
/ 4.0
Class rank: ______ out of ______ OR
within top ______%,
(preferred) OR
_____Quartile
_
___ Students at this school receive a pass/fail grade. Student is (mark one): ____PASSING ___ NOT PASSING
_
___ School does not apply class rank. Comments:
School Official: Signature
Title
Name and Title: Date:
Email:
If awarded, the scholarship check will be made out to the student and sent to the school for deposit into the student’s account. Please send the scholarship check to the following individual/department: Name: First/Last
Title
Address:
Email/Phone: Email
Phone
* NOTE: Dental School GPA – If school uses a pass/fail or point system, please convert to grade point average (GPA) and calculate on a 4.0 scale. ** NOTE: Class Rank – If the school does not use a GPA or Class Ranking System, please indicate which quartile the student ranks within the class. This information is required in order for the application to be considered.
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C. FINANCIAL NEED ASSESSMENT: Please complete this Financial Needs Assessment form. It must be signed by a dental school financial aid officer. Please complete both sides of the table below. Do not consolidate categories listed below. Anticipated Annual Financial Resources
Amount
Other Anticipated Grants & Scholarships
$ ____________
Annual Employment Earnings* (include only the amount actually used to pay school expenses.)*
$ ____________
Family Contribution* (include only the amount actually used to pay school expenses.)
$ ____________
Anticipated Annual Expenses for Second Year of Dental School
Tuition & Fees
Amount
$ _____________
Books/Supplies $ _____________
Living Expenses / Room and Board
$ _____________
Transportation and Miscellaneous Expenses
$ _____________
B. Total Anticipated Expenses
$ _____________
Calculation of Unmet Financial Need >>>
A. Total Resources (must match “A. Total Resources,” left)
$ ______________
*Please list only the actual amount paid from Family Contribution & Employment Earnings rather than the amount identified via FAFSA. Please verbally ask the applicant for this information. Do not include loans.
minus
A.
Total Resources (add a, b, c)
$ ___________
$ ______________ B. Total Expenses equals Unmet Financial Need
$ ______________
Financial Aid Officer’s Signature: Signature
Date
Financial Aid Officer’s Name: Title:
Telephone:
Email:
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D. REFERENCE FORMS REQUIRED The ADAF requires two completed Reference Forms, of which at least one must be from a dental school representatives (e.g., associate/assistant dean of academics, student affairs or director with similar title). Reference #1:
Name
Organization
Title
Email
Reference #2:
Name
Organization
Title
Email
E. BIOGRAPHICAL SKETCH QUESTIONNAIRE The Biographical Sketch Form on page 8 contains specific questions designed to assist you in describing why the scholarship is important to describe leadership, research, service achievements, and volunteerism attributes of the applicant (if applicable). Please type your responses. F. APPLICANT STATEMENTS I hereby authorize the release of information about my academic status to the ADA Foundation only for the purpose of evaluating my application for the Dental Student Scholarship, I hereby affirm that all of the information contained herein is correct, and that I am a U.S. citizen. If applying for the Underrepresented Minority Dental Student Scholarship, I affirm that I am a member of one of the following minority groups underrepresented in dental school enrollment: African American, Hispanic, or Native American/Alaska Native. I am currently enrolled in a predoctoral course of studies to obtain a dental degree at an institution accredited by the Commission on Dental Accreditation of the American Dental Association.
I understand that misrepresentation, fraud, or omission of facts is cause for disqualification or suspension of a scholarship. Name:
Signature:
Date:
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D. REFERENCE FORM #1 To the Applicant:
Please type your name in the space provided, and check (√) the appropriate box to indicate the Scholarship for which you are applying.
Applicant’s Name (Type): ADAF Dental Student Scholarship ADAF Underrepresented Minority Dental Student Scholarship
To the Referrer:
The Applicant is applying to the ADAF for the scholarship checked above. To help ensure confidentiality, please complete this form and return it to the Applicant in a sealed envelope.
1. Knowledge of the Applicant (Please check (√) all that applies) I have known the Applicant for
Year(s)
Months(s)
(e.g., 3 years and 6 months) I know the Applicant Nature of my contact with the Applicant
2. Evaluation of the Applicant
Very well
Moderately well
Academic
Other:
Truly Exceptional
Excellent
Good
Slightly
No Comment
Academic knowledge Interpersonal communication skills Collegial with peer students Demonstrates ethical conduct Demonstrates leadership / leadership potential Professionalism
NOTE: Please include a letter of reference on an additional sheet of paper.
Name of Referrer:
Signature: (Please Type)
Position/Title:
Department:
Institution: Telephone Number:
(
)
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D. REFERENCE FORM #2 To the Applicant:
Please type your name in the space provided, and check (√) the appropriate box to indicate the Scholarship for which you are applying.
Applicant’s Name (Type): ADAF Dental Student Scholarship ADAF Underrepresented Minority Dental Student Scholarship To the Referrer:
The Applicant is applying to the ADAF for the scholarship checked above. To help ensure confidentiality, please complete this form and return it to the Applicant in a sealed envelope.
1. Knowledge of the Applicant (Please check (√) all that applies) I have known the Applicant for
Year(s)
Months(s)
(e.g., 3 years and 6 months) I know the Applicant Nature of my contact with the Applicant 2. Evaluation of the Applicant
Very well
Moderately well
Academic
Other:
Truly Exceptional
Excellent
Good
Slightly
No Comment
Academic knowledge Interpersonal communication skills Collegial with peer students Demonstrates ethical conduct Demonstrates leadership / leadership potential Professionalism
NOTE: Please include a letter of reference on an additional sheet of paper.
Name of Referrer:
Signature: (Please Type)
Position/Title:
Department:
Institution: Telephone Number:
(
)
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E. BIOGRAPHICAL SKETCH – (To be completed by the applicant) Type Name:
Date:
Signature:
PLEASE TYPE 1. Please explain why this scholarship is important to you. Provide reasons other than education-related debt.
2. Briefly provide specific examples of the academic, leadership, research, service achievements, and /or volunteerism attributes that you believe qualify you as a candidate for this scholarship.
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9
10
11
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At least 25 awards
$2,500 each
Up to $62,500 total funding
At least 25 awards Up to two awards Up to two awards Up to 54
$2,500 each $2,500 each $2,500 each
Up to $62,500 total funding Up to $5,000 total Up to $5,000 total Up to $135,000 total funding
Eligibility Criteria: In order to be eligible for consideration for these scholarships, an applicant must: Be enrolled in the second year of study at the time of application, in a U.S. accredited dental school; Be enrolled as a full-time student; Demonstrate a minimum financial need of $2,500; Have a minimum accumulative grade point average of 3.25 based on a 4.0 scale; and Submit two completed reference forms and letters of reference, at least one of which letters must be submitted by one of the following: Associate/Assistant Dean/Director of Student Services, Associate/Assistant Dean of Financial Aid, Associate Assistant Dean of Academic Affairs or appropriate designee of the School of Dentistry. In the case of ADAF Underrepresented Minority Dental Student Scholarships applicants, must be a member of one of the following minority groups underrepresented in dental school enrollment: African American, Hispanic, or Native American/Alaska Native. In the case of applicants for the Dr. Robert B. Dewhirst scholarships, must be enrolled at the University of California at Los Angeles School of Dentistry or the Herman Ostrow School of Dentistry of the University of Southern California USC.
Scholarship Timetable: Scholarship Application Available: Applications due to ADAF: Notification of scholarship awards:
September 7, 2015 November 13, 2015 January, 2016
1
Evaluation of Applications: Scholarship decisions and award amounts are in the sole discretion of the ADAF Board of Directors. Scholarship applications are evaluated based on a 40 point scale as follows, with 40 points being the highest possible score and 0 being the lowest score: Academic Achievement: Financial Needs Assessment: Reference Forms: Biographical Sketch:
maximum of 10 points maximum of 10 points maximum of 10 points maximum of 10 points
Scholarship Agreement: Each scholarship recipient will be required to sign a Scholarship Agreement indicating consent to the terms of the award and confirming that all information submitted is accurate. Application Submission and Review Processes: Dental school faculty and staff members are encouraged to notify students of the availability of the Scholarships using appropriate resources and technology. The application form is attached to these guidelines and are also available at www.adafoundation.org. Each accredited dental school may submit the following number of applications to the ADAF Dental Student Scholarship Program each year: o A limit of five per school for the ADAF Underrepresented Minority Dental Student Scholarships, and o A limit of one per school for the ADAF Dental Student Scholarships. o Each dental school is encouraged to submit at least one candidate for each scholarship. The recipients of the Robert J. Sullivan Scholarships and Dr. Robert B. Dewhirst Scholarships will be selected from among submitted applications (Dewhirst scholarships are limited to the schools noted). Incomplete or late applications will not receive consideration. If confirmation of receipt of the submitted application is required, please arrange to receive confirmation from the shipping vendor or U.S. Post Office. The ADA Foundation cannot confirm receipt of applications. Students who are awarded scholarships and their school officials will be notified of the award by ADAF staff. A list of scholarship winners will be posted on the ADA Foundation’s website (www.adafoundation.org) by the end of January. Applicants not selected for a scholarship will not appear on the list. Policy Statements: The ADAF does not discriminate on the basis of race, color, gender, sexual orientation, age, religion, political affiliation, national or ethnic origin, or disability. The scholarship programs are competitive, and submitting an application does not confer the right to receive a scholarship, nor ensure that an applicant will receive a scholarship. Additional Information: If you have any questions or need additional information, please contact Tracey Schilligo, ADA Foundation Grants Program Manager, at 312.440.2763 or [email protected]. The ADAF regularly updates its website, www.adafoundation.org. Please check the website for the most current program information.
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211 East Chicago Avenue, Suite 2100 Chicago, Illinois 60611-2678 (312) 440-2763 E-mail: [email protected]
ADA FOUNDATION DENTAL STUDENT SCHOLARSHIP and UNDERREPRESENTED MINOIRTY DENTAL STUDENT SCHOLARSHIP APPLICATION Deadline: Application must be received by November 13, 2015 Thank you for your interest in the ADA Foundation (“ADAF”) Dental Student Scholarship. INSTRUCTIONS: This application is an MS Word document. Please open and save it to your computer. The application must be typed in this Word document. An official dental school representative is responsible for submitting the application. The ADAF must receive all application materials in its office no later than November 13, 2015, by close of business. Due to the inclusion of sealed reference letters, applications must be submitted in paper format (via U.S. Mail, FedEx, UPS, etc.). Incomplete or late applications will not receive a response or consideration. If you require confirmation of receipt of your application, please request that confirmation with your shipping vendor or U.S. Post Office. The ADAF does not confirm receipt of applications. Mail to: ADA Foundation Attn: Scholarship Program 211 East Chicago Avenue, Suite 2100 Chicago, IL 60611-2637
ELIGIBILITY: To be eligible for this scholarship, the applicant must be a U.S. citizen and currently enrolled as a full-time student in his or her second year of study in an accredited dental degree program at the time of application. Applicants for the Underrepresented Minority Dental Student Scholarship Program must be a member of one of the following minority groups: African American, Hispanic, or Native American/Alaska Native.
AWARD: The maximum annual award for the ADAF Dental Student Scholarship is $2,500, and should be used for education based expenses.
1
A.
GENERAL INFORMATION
Name: Last
First
Middle
Current Address: Number and Street City
State
ZIP
Permanent Address: Number and Street City
State
Current Telephone:
ZIP
Email : Yes ______
U.S. Citizen:
No ______
______Dental Student Scholarship
OR
______ Underrepresented Minority Dental Student
I am Applying For: Scholarship
Underrepresented Minority Dental Student Scholarship applicants only,
____ African American
please indicate:
____Native American/Alaska Native
School of Dentistry in which you are enrolled: School: Street Address: City/State/ZIP Telephone:
Please provide the name and email address for the following: Associate / Assistant Dean of Student Affairs or
Email:
Academic Affairs Name and title
Financial Aid Officer:
Email: Name and title
2
____Hispanic
B.
VERIFICATION OF ACADEMIC ACHIEVEMENT RECORD (To be completed and signed by a School Official)
_________________________________________________________________________________________________________ (Type Student’s Complete Name) The student named in Section A is applying for the ADA Foundation Dental Student Scholarship. In order to consider this student’s application, it is necessary to have the Academic Achievement Record confirmed. The student must have a minimum cumulative program grade point average of 3.25 based on a 4.0 scale.* Cumulative GPA*/Class Rank**:
GPA:
/ 4.0
Class rank: ______ out of ______ OR
within top ______%,
(preferred) OR
_____Quartile
_
___ Students at this school receive a pass/fail grade. Student is (mark one): ____PASSING ___ NOT PASSING
_
___ School does not apply class rank. Comments:
School Official: Signature
Title
Name and Title: Date:
Email:
If awarded, the scholarship check will be made out to the student and sent to the school for deposit into the student’s account. Please send the scholarship check to the following individual/department: Name: First/Last
Title
Address:
Email/Phone: Email
Phone
* NOTE: Dental School GPA – If school uses a pass/fail or point system, please convert to grade point average (GPA) and calculate on a 4.0 scale. ** NOTE: Class Rank – If the school does not use a GPA or Class Ranking System, please indicate which quartile the student ranks within the class. This information is required in order for the application to be considered.
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C. FINANCIAL NEED ASSESSMENT: Please complete this Financial Needs Assessment form. It must be signed by a dental school financial aid officer. Please complete both sides of the table below. Do not consolidate categories listed below. Anticipated Annual Financial Resources
Amount
Other Anticipated Grants & Scholarships
$ ____________
Annual Employment Earnings* (include only the amount actually used to pay school expenses.)*
$ ____________
Family Contribution* (include only the amount actually used to pay school expenses.)
$ ____________
Anticipated Annual Expenses for Second Year of Dental School
Tuition & Fees
Amount
$ _____________
Books/Supplies $ _____________
Living Expenses / Room and Board
$ _____________
Transportation and Miscellaneous Expenses
$ _____________
B. Total Anticipated Expenses
$ _____________
Calculation of Unmet Financial Need >>>
A. Total Resources (must match “A. Total Resources,” left)
$ ______________
*Please list only the actual amount paid from Family Contribution & Employment Earnings rather than the amount identified via FAFSA. Please verbally ask the applicant for this information. Do not include loans.
minus
A.
Total Resources (add a, b, c)
$ ___________
$ ______________ B. Total Expenses equals Unmet Financial Need
$ ______________
Financial Aid Officer’s Signature: Signature
Date
Financial Aid Officer’s Name: Title:
Telephone:
Email:
4
D. REFERENCE FORMS REQUIRED The ADAF requires two completed Reference Forms, of which at least one must be from a dental school representatives (e.g., associate/assistant dean of academics, student affairs or director with similar title). Reference #1:
Name
Organization
Title
Reference #2:
Name
Organization
Title
E. BIOGRAPHICAL SKETCH QUESTIONNAIRE The Biographical Sketch Form on page 8 contains specific questions designed to assist you in describing why the scholarship is important to describe leadership, research, service achievements, and volunteerism attributes of the applicant (if applicable). Please type your responses. F. APPLICANT STATEMENTS I hereby authorize the release of information about my academic status to the ADA Foundation only for the purpose of evaluating my application for the Dental Student Scholarship, I hereby affirm that all of the information contained herein is correct, and that I am a U.S. citizen. If applying for the Underrepresented Minority Dental Student Scholarship, I affirm that I am a member of one of the following minority groups underrepresented in dental school enrollment: African American, Hispanic, or Native American/Alaska Native. I am currently enrolled in a predoctoral course of studies to obtain a dental degree at an institution accredited by the Commission on Dental Accreditation of the American Dental Association.
I understand that misrepresentation, fraud, or omission of facts is cause for disqualification or suspension of a scholarship. Name:
Signature:
Date:
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D. REFERENCE FORM #1 To the Applicant:
Please type your name in the space provided, and check (√) the appropriate box to indicate the Scholarship for which you are applying.
Applicant’s Name (Type): ADAF Dental Student Scholarship ADAF Underrepresented Minority Dental Student Scholarship
To the Referrer:
The Applicant is applying to the ADAF for the scholarship checked above. To help ensure confidentiality, please complete this form and return it to the Applicant in a sealed envelope.
1. Knowledge of the Applicant (Please check (√) all that applies) I have known the Applicant for
Year(s)
Months(s)
(e.g., 3 years and 6 months) I know the Applicant Nature of my contact with the Applicant
2. Evaluation of the Applicant
Very well
Moderately well
Academic
Other:
Truly Exceptional
Excellent
Good
Slightly
No Comment
Academic knowledge Interpersonal communication skills Collegial with peer students Demonstrates ethical conduct Demonstrates leadership / leadership potential Professionalism
NOTE: Please include a letter of reference on an additional sheet of paper.
Name of Referrer:
Signature: (Please Type)
Position/Title:
Department:
Institution: Telephone Number:
(
)
6
D. REFERENCE FORM #2 To the Applicant:
Please type your name in the space provided, and check (√) the appropriate box to indicate the Scholarship for which you are applying.
Applicant’s Name (Type): ADAF Dental Student Scholarship ADAF Underrepresented Minority Dental Student Scholarship To the Referrer:
The Applicant is applying to the ADAF for the scholarship checked above. To help ensure confidentiality, please complete this form and return it to the Applicant in a sealed envelope.
1. Knowledge of the Applicant (Please check (√) all that applies) I have known the Applicant for
Year(s)
Months(s)
(e.g., 3 years and 6 months) I know the Applicant Nature of my contact with the Applicant 2. Evaluation of the Applicant
Very well
Moderately well
Academic
Other:
Truly Exceptional
Excellent
Good
Slightly
No Comment
Academic knowledge Interpersonal communication skills Collegial with peer students Demonstrates ethical conduct Demonstrates leadership / leadership potential Professionalism
NOTE: Please include a letter of reference on an additional sheet of paper.
Name of Referrer:
Signature: (Please Type)
Position/Title:
Department:
Institution: Telephone Number:
(
)
7
E. BIOGRAPHICAL SKETCH – (To be completed by the applicant) Type Name:
Date:
Signature:
PLEASE TYPE 1. Please explain why this scholarship is important to you. Provide reasons other than education-related debt.
2. Briefly provide specific examples of the academic, leadership, research, service achievements, and /or volunteerism attributes that you believe qualify you as a candidate for this scholarship.
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9
10
11
12
