2016 – 2017 Scholarship for Service (SFS)

Please return this application to

UTSA Department of Computer Science

FLN 4.01.10

One UTSA Circle

San Antonio, Texas 78249

Last name (please print) / First name / Middle name
@ / Male / Female / (Circle one)
Student ID number
Mailing address Number/street / City / County / State Zip
E-mail address / Name of high school
( ) / ( )
Home phone number / Cell phone number
Application for (circle one): (Graduate SFS Scholarship) (Undergraduate SFS Scholarship)
Are you a current UTSA Student? ❑ Yes ❑ No
Are you a Texas resident? ❑ Yes ❑ No Are you a U.S. Citizen? ❑ Yes ❑ No
Do you currently hold or are you eligible (i.e. can you pass a background check) for a U.S. Security Clearance? ❑ Yes ❑ No
Are you within 3 years of the completion of your degree? ❑ Yes ❑ No Within 2 years? ❑ Yes ❑ No
Are you the first in your immediate family (father, mother, brother, sister, aunt, uncle) to attend college? ❑ Yes ❑ No
If no, please indicate relationship of relative and level of education attained: some college ❑ college degree ❑
Do you have a disability? ❑ Yes ❑ No
If yes, please attach documentation of your disability (must be within three years)
Under the ADA, an individual with a disability is a person who has a physical or mental impairment that substantially limits one or more major life activities; has a record of such impairment; or is regarded as having such impairment.
Are you fluent in a language other than English? ❑ Yes ❑ No If yes, what language(s)? ______
Do you understand that acceptance of an SFS scholarship means that you agree to one year of employment with a Federal Agency (such as the FBI, CIA, NSA, DoD, DOE, or DOJ) for every year of support in the program and that you are required to complete a summer government internship if you receive a scholarship for more than 1 year? ❑ Yes ❑ No
Do you understand that if you are accepted for the scholarship but are unable to complete the degree you will be required to pay back any money you have received through the NSF/SFS program? ❑ Yes ❑ No
Do you understand that you will be responsible for, and agree to, apply for and obtain a government (Federal, State, Local, Tribal, or Territorial) position to fulfill the service obligation? ❑ Yes ❑ No
Please include with your application 2 letters of recommendation from faculty members at UTSA or another educational institution.
Academics (to be filled out for Undergraduate Scholarship Applicants) / ❑ Yes ❑ No

If you are a transfer student, name of college transferred from: ______GPA ______

If you are a Computer Science Major, Semester Hours of CS Completed: ______Computer Science GPA ______

If you are an Information Systems or Information Assurance Major,

Semester Hours of IS or IA Completed: ______IS or IA GPA ______

If you are not majoring in CS, IA, or IS, what is your major? ______GPA: ______

Anticipated Graduation Date: ______Type of scholarship requested (circle one): 1 year 2 years 2 or 3 years

Signature: ______

______

Academics (to be filled out for Graduate Scholarship Applicants)

Where did you obtain your undergraduate degree? ______

What major was your undergraduate degree in? ______

What was your cumulative undergraduate GPA? ______Comp Sci, IS, or IA GPA ______

What program are you in? ______Degree sought: (Circle one)? MS PhD

What is your current graduate GPA? ______

Anticipated Graduation Date: ______Type of scholarship requested (circle one): 1 year 2 years 2 or 3 years

Signature: ______

Statement of Purpose and/or Essay question (see individual scholarship qualifications for essay requirements):

Attach to this application any required essay along with a narrative describing your background, career interests and professional goals and statement of purpose for applying for this scholarship. Please include your name and college admission I.D. number stated at the top of your attachments.

High School Activities: List all school activities in which you have participated in the last four years (i.e., student government, athletics, clubs, etc.). List all academic honors, scholarships, fellowships and assistantships. Attach additional pages if necessary. Activities Year (1, 2, 3, 4) Position Total months participated Avg. hours per week. Please include your name and college admission I.D. number stated at the top of your attachments.

College Activities: List all clubs, organizations, student government, etc. If any activities involved leadership positions, please indicate. List all academic honors, scholarships, fellowships and assistantships. Attach additional pages if necessary. From month/year To month/year Description of activity Leadership position held. Please include your name and college admission I.D. number stated at the top of your attachments.

Research Interests and Publications, if any: Attach additional pages if necessary. Please include your name and college admission I.D. number stated at the top of your attachments.

Community and Volunteer Activities: List all non-paid community activities in which you have participated in the last four years (i.e., charity groups, church, hospitals, etc.). Include any memberships in professional organizations. Attach additional pages if necessary. Activity (e.g. soup kitchen) Year (1,2,3,4) Position Total months worked Avg. hours per month Comment: Certification (must be signed by all applicants) Please include your name and college admission I.D. number stated at the top of your attachments.

Resume: Please attach a resume if you are currently employed including your current position and hours per week working.

Applicant’s Signature / Date

I certify that the information on this application is correct and true to the best of my knowledge. I hereby give permission for this information to be released to the donor or potential donors of any scholarship for which I may be eligible. I also give my permission to release my information to the donor of any scholarship for which I am selected. I also understand that furnishing false information may result in revocation of my financial aid or may result in disciplinary action pursuant to the UTSA Code of Student Conduct.

Privacy Notice

With few exceptions, you are entitled to be informed about the information U.T. San Antonio collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review this information. Under Section 559.004 of the Texas Government Code, you are entitled to have U.T. San Antonio correct information about you that is held by us and that is incorrect, in accordance with the procedures set forth in the University of Texas System Business Procedures Memorandum 32. The information that U.T. San Antonio collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of information are kept for different periods of time.