NAME: _____________________________________________________

  ADDRESS: _____________________________________________________

                   _____________________________________________________

                   _____________________________________________________

TELEPHONE:_____________________ 2ND TEL:_______________________

   E-MAIL:________________________ SS#_________________________

SCHOOLS ATTENDED  
HIGH SCHOOL         ADDRESS        COURSE            DATES       GPA
                                  OF STUDY

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

HIGHER EDUCATION
SCHOOL            ADDRESS         COURSE             DATES          DEGREES    GPA
                                  OF STUDY

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

ACADEMIC PLANS FOR 2011-2012


Please list below the higher educational institution and degree program you anticipate attending during the 2011-2012
 academic year. If you currently are applying to schools, please list these schools below.

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

1.Confidential letters of reference will be sent directly to the VSGC by:
          NAME                   TITLE                   ADDRESS

1.____________________________________________________________________________

2.____________________________________________________________________________

3.____________________________________________________________________________

The following information is optional, although essential for our national reporting. The VSGC
encourages full participation in its programs by women and members of minority groups.

     Male___ Female___ Minority Origin_____ Handicapped_____

       Are you a Vermont resident and United States citizen?   _____Yes    _____No

IMPORTANT NOTES: This application should be accompanied by an essay detailing your career plans and the relationship of these plans to areas of interest to NASA. This essay (NOT TO EXCEED 3 TYPED, DOUBLE-SPACED PAGES) should be as detailed and specific as possible. Current VSGC Scholars applying for an additional year of funding should also include a short Progress Report. Please see the VSGC Undergraduate Scholarship Fact Sheet for important details concerning both the essay and the Progress Report.

*Scholarships are not automatically renewable and awardees must complete all requirements when reapplying.

The completed application form, essay, and Progress Report (if appropriate) should be mailed to the VSGC office:

Vermont Space Grant Consortium/NASA EPSoR
Votey Building
College of Engineering and Mathematics
University of Vermont
Burlington, VT 05405-0156
Telephone:(802) 656-1429,
Fax:(802) 656-1102, (802)-656-8802

You should also arrange for official transcripts of your academic record to be sent to VSGC at the above address.

TO BE ELIGIBLE FOR THE 2011-2012  SCHOLARSHIP COMPETITION:
All application materials, including completed form, essay, Progress Report (if appropriate), transcripts, and three letters of reference, MUST BE RECEIVED NO LATER THAN APRIL 13

• VSGC office is located in Rm 209, 12 Colchester Ave, (2nd floor) next to the UVM Mathematics Bldg.
• Contact can also be made via direct email: zeno@cems.uvm.edu, or through the: VSGC html page: http://www.cems.uvm.edu/VSGC