This application can not be saved for future use, you must fill it out completely before submission to SHPE. Feel free to print this page now and work on the application at your leisure. If you have any questions, please see the SHPE website for more information.

Select Scholarship
*Scholarship:	-- Select Scholarship -- 2012-2013 Dissertation Scholarship 2012-2013 General Scholarship 2012-2013 Northrop Grumman Scholarship 2012-2013 Professional Scholarship 2012-2013 Verizon Scholarship

A. Personal And Background Information
*Name	firstmilast
*Gender:	Male Female
Student Permanent Home Address
*E-Mail Address:
*Telephone:
*Address:
Address 2:
*City, State ZIP	city Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming statezip
*County	-- Select County -- (select state first)
*Congressional District:
	Click here for help finding your congressional district.
Student Mailing Address at University (if different from above)
E-Mail Address:
Telephone:
Address:
Address 2:
*City, State ZIP	city Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming statezip
* Race/Ethnicity
Central American Cuban Dominican Mexican American Puerto Rican South American Spanish White/Anglo Black/African American Asian/Pacific Islander   Native American/American Indian   --  Tribal Affiliation Other
Residency
*Citizenship Status:	U.S. Citizen Permanent Resident Temporary Resident (F1 Visa Student) Other
Parental/Sibling Education
*Mothers Highest Educational Attainment No formal education Less than 8th grade Some high school HS Diploma GED Some college Associates degree Bachelors degree Masters degree Doctorate/Professional I do not know Not applicable
*Fathers Highest Educational Attainment No formal education Less than 8th grade Some high school HS Diploma GED Some college Associates degree Bachelors degree Masters degree Doctorate/Professional I do not know Not applicable
*Some of my brothers/sisters are attending/attended college?:	Yes No I do not have any siblings
*Some of my brothers/sisters have received a bachelor's degree?:	Yes No I do not have any siblings

B. Academic Information
*I am a:	High School Student Undergraduate Student Graduate Student
High School Students
*High School:
*School City:
*School State:	Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
*College/University You Plan to Atttend	Select University
*Major Field of Study:
*Expected Graduation Date:
*Expected College Enrollment Date:
*Cumulative GPA (On a 4.0 Scale):
Undergraduate Students
*Classification:	Freshman Sophomore Junior Senior
*Are you graduating (or graduated) from college and applying for funding for your first-year of graduate school to start in fall 2012?:	Yes No
*College/University	Select University
*Major Field of Study:
Minor Field of Study:
*Credit Hours Completed:
*GPA (On a 4.0 Scale):
*Expected Graduation Date:
*Did you transfer from a community college?:	Yes No
If you are attending a community college, do you intend to transfer to a 4-year college or university?:	Yes No
If yes, which college/university?	Select University
Including the current year, how many years did you attend a community college?:
If you have previously received a SHPE scholarship, please enter when:
Graduate Students
*Classification:	Masters Doctoral Student Doctoral Candidate
*College/University	Select University
*Major Field of Study:
Minor Field of Study:
*Credit Hours Completed:
*GPA (On a 4.0 Scale):
*Expected Graduation Date:
If you have previously received a SHPE scholarship, please enter when:

C. Financial Information
*Parents Marital Status:	Single Married Separated Divorced Widowed
*Your Marital Status:	Single Married Separated Divorced Widowed
*Mothers Occupation:
*Father Occupation:
*Number of individuals your parents can claim as dependents on their 2010 tax return?:
*How many in your immediate family are currently attending college? (Include Yourself):
*How many in your immediate family have graduated with Bachelor's degree? (Include Yourself):
*Do your parent(s) contribute to your educational expenses?:	Yes No
*Do you live with your parent(s)?:	Yes No
*Did you complete a FAFSA for 2012-2013?:	Yes No
If not, will you complete a FAFSA for 2012-2013?:	Yes No
*Are you currently employed?:	No Yes, quarter-time Yes, half-time Yes, full-time
Who is your employer?:
What is your job title?:
On average, how many hours do you plan to work each week during the academic year:	(enter 0 if none)
*Do you plan on borrowing a student loan or PLUS loan?:	Yes No
*What is your expected tuition and fees for the 2012-13 academic year? (do not include room, board, books, misc.):
Please list the other scholarships/fellowships you applied or are applying to for the next school year
2011 Total Family Income
*Mother Gross Income:	(i.e. 5000, no dollar signs or decimals)
*Father Gross Income:	(i.e. 5000)
*Applicant Gross Income:	(i.e. 5000)
*Spouse Gross Income:	(i.e. 5000)
*Other Income:	(i.e. 5000)
If your income for 2012 will change significantly, explain how and why.

D. SHPE Background
*Are you a SHPE member?:	Yes No
*I have been a SHPE member for at least Less than 3 months 3 months 6 months 12 months 2 years 3 years 4 years 5 years More than 5 years
How many years have you held a leadership position in SHPE:
How many times have you presented a technical paper or research poster or competed in the design competition at the SHPE Conference:

* E. Personal Statement
Please include a succinct (maximum 500 words) personal statement which uniquely addresses each of the following elements: community involvement leadership academic achievement(s) research/scholarship/co-op experience(s) short-term and long-term goal(s) and aspiration(s). Be sure to include any information you feel the scholarship review committee should consider when reviewing your application.

© Copyright 2009 SHPE Inc. ¤ 32 Years of Excellence