_________________________________
_______________________________
Name
Student ID
_______________________________________________________________________________________________
Street Address
City
State
Zip
____________________________ _________________________
Daytime Telephone, with area code
Evening Telephone, with area code
____________________________
_____________
e-mail address (please print clearly)
Date of Birth
Citizenship Status (circle one): U.S. Citizen or
National
Permanent Resident
Refugee Alien
Previous Education: ________________________
What school?
____________________________
Date of admission to UMass Boston _________ Major ___________________________________
Number of credits earned at UMass Boston ___________
Estimated graduation date ___________________
Career Goal
___________________________________________________
Other institutions: List all other colleges you have
attended
______________________________________________________________________________________
Estimate the amount you owe in educational
loans __________________________
Were you eligible for student financial aid
through UMass Boston for the previous academic year? ___ Yes ____ No
(Note:
If you answer "no", then you are not eligible for a
scholarship and should not complete this application.)
What is the total amount of aid you are
receiving that does not have to be repaid? ___________________
What is the total amount of aid you are
receiving that does have to be repaid (loans)? _________________
Total amount of aid you received last year
through the Office of Merit-based Scholarships __________
During the school year, how many hours per week do you work? _________________
List your current employment information
Name of company _________________________
Dates of employment ________________________
Duties
_______________________________________________________________________________
DEMOGRAPHIC INFORMATION
The following information is optional and will not affect your
application. You are asked to
provide this information by the National Science Foundation, for demographic
purposes.
Gender: ____ Male
_____ Female
Ethnicity (check one): ____ Hispanic or Latino _____ Not
Hispanic or Latino
Racial Background (check all that apply):
_____ American Indian or
_____ Asian
_____ Black or African-American
_____ Native Hawaiian or Other Pacific Islander
_____ White
Disability Status (check all that apply):
_____ Hearing Impaired
_____ Visual Impaired
_____ Mobility/Orthopedic Impaired
_____ Learning Disability
_____ None
I certify that
all the information on this application is true. My signature further signifies my
permission to release all information contained in my Scholarship Application
Packet, as well as relevant information on record at the
Signature: ______________________________ Date: ______________
________________________________________________________________________
Application package checklist:
____ completed application
____ most recent transcript
____ statement of career goals
____ letter of recommendation arranged to be sent to Prof. Cohen
____ financial aid statement (optional)
When complete, please send the application to:
Prof. Robert Cohen
Department of Computer Science
UMass Boston
You may also drop it off in his
mailbox in the Math/CS office (S-3-132).
Completed applications are due by