Basic Scholarship & Grant Application

A. PERSONAL DATA

1 / Name (Last, First, M.I.)
, , / Other Last Names Used (if applicable)
2 / Mailing Address (correspondence will be mailed here) / E-mail Address (correspondence will be emailed here)
3 / City / State / Zip Code / Tel No. - -
4 / Date of Birth (mm/dd/yyyy) / Sex
Male Female / Veteran?
No Yes
5 / Are you related to a current Board member of The CIRI Foundation? (not Cook Inlet Region, Inc.)
No Yes If yes, provide their name and your relationship.
B. ELIGIBILITY
6 / My ANCSA Regional Corporation is: (Check all that apply) / Ahtna Aleut ASRC BSNC BBNC Calista Chugach
CIRI Doyon Koniag NANA Sealaska Other
7 / I certify that I am an Alaska Native (Check only one) CIRI Shareholder -or- Direct Lineal Descendant
8 / I am a direct lineal descendant of CIRI Shareholder: (Last, First, M.I.) , , / Relationship to shareholder:
9 / I am a Tribal member of the following Cook Inlet Region village:
Chickaloon Village Traditional Council Native Village of Tyonek (not Tebughna Foundation funding)
Ninilchik Traditional Council Kenaitze Indian Tribe Knik Tribal Council
Salamatof Tribal Council None
10 / I am applying for the following CITC Scholarship Deadline: / June 1 December 1 (select only one)
11 / Have you applied to CITC before? No Yes If yes, when?
12 / I am enrolled in an Alyeska Match qualifying program (programs noted on pg. 9) and I would like to be considered for Alyeska Match Funding No Yes

C. EDUCATION LEVEL & EDUCATION HISTORY

13 / I am currently in college: Freshman (0-29 cr.) Sophomore (30-59 cr.) Junior (60-94 cr.)
Senior (95+ cr.) Graduate Degree PhD
14 / Check ALL that apply -AND- enter date of completion
I am currently in High School Date: / /
I am a High School Graduate Date: / /
I have a General Education Diploma (GED) Date: / /
I have a vocational training/certificate Date: / /
I have a 2-year Associates Degree Date: / /
I have a 4-year Degree Date: / /
I have a Master’s Degree or PhD Date: / /
I have not been enrolled in the past five years – still required to submit most recent transcripts

D. EDUCATION PLANS

15 / Name of School
16 / Financial Aid Office Address - If awarded, this is where the check is mailed to / Telephone No.
- -
17 / City / State / Zip Code / Fax No.
- -
18 / Current Degree Program: 2-year Associates 4-year Bachelors Masters Doctorate
19 / I am applying for the:
Fall: Spring: Winter/Spring: / Term Start Date: Term End Date:
*Note: You cannot apply for courses completed prior to the application deadline.
20 / My school calendar is based on: Semesters Trimesters Quarters Other:
21 / I will be enrolled: Full-time -or- Part-time during the term listed above.
22 / I will be taking (#) credits for the term dates listed above.
***Please immediately send TCF written notification of any schedule or enrollment changes.***
23 / Check this box if your program is online, distance-delivery, or correspondence.
24 / Declared Major: If declared, what is your field of study?
Declared Minor: If you have declared a minor, what is your field of study?
Undeclared
25 / Expected Graduation Date: / /
26 / My most recent cumulative grade point average (GPA) is: (If most current education is GED, put 2.5 for GPA)
27 / I understand that I am expected to complete all of the courses and credits for which I receive funding from CITC (check box).

E. BUDGET FORECAST

Complete your education budget for the term specified on line #21.
Do not leave any blanks. If the amount is zero, put -0-.
28 / While attending school, will you be living in on-campus housing provided by your school? Yes No
A. EXPENSES / AMOUNT / B. SOURCES OF FUNDS / AMOUNT
Direct Academic Costs
Tuition / $ / Personal/family contribution to education / $
29 / Student fees / $ / Tuition waiver / $
Books & required supplies / $ / Veterans Administration Aid / $
Room and Meal Plan Costs (§) / State/Federal Social Security / $
On-campus housing / $ / State/Federal Student Loans / Grants / $
On-campus meal plan / $ / Other Scholarships / Grants / $
Other Tribal Scholarships / Grants / $
Other (specify): / $
TOTAL EXPENSES / $ / TOTAL SOURCES OF FUNDS / $
Amount Needed=(Total EXPENSES - total FUNDS) / $
§ Only students living in school-provided, on-campus housing are eligible to use award funds toward housing and/or meal plan costs.
28 / I am receiving other scholarships or grants: No Yes
If yes, list all other funding sources. Please note any funding awarded from other Alyeska Sources (i.e. Internships, scholarships, etc.) *See Pg. 11 for full list of Alyeska partner organizations.

F. CERTIFICATION (READ CAREFULLY)

29 / By signing this statement, I acknowledge that I have read and agree to the funding guidelines and terms specified below:
1. To the best of my knowledge, the information in this application is true, correct and complete.
2. It is my responsibility - not that of The CIRI Foundation (board or staff) or any other party (e.g. parent, spouse, academic advisor) – to obtain and submit all the necessary application materials on or before the deadline to receive consideration for any award.
3. I give The CIRI Foundation permission to access my previous scholarship and grant applications, and supporting documents on file with Cook Inlet Tribal Council, for the purpose of processing current and future applications with The CIRI Foundation.
4. This application does not obligate The CIRI Foundation to award an education scholarship or to pay any costs incurred in the submission of this application. All decisions made by TCF are final.
5. If approved for a scholarship or grant, I agree to abide by the terms and conditions of the award. If, for any reason, I am unable to use the award for which I am selected, the full amount or any portion thereof is to be refunded to The CIRI Foundation.
6. I understand that I am required to complete all courses and credits for which I am funded for by CITC.
7. All applicant information is kept confidential in accordance with the Family Education Rights and Privacy Act of 1974. Information will not be released to another party, including parents or family members, without having written consent of the applicant.
8. I give The CIRI Foundation permission to release, as appropriate, my comments, photo, name, address, email, and telephone number for employment or education referrals and CIRI, CITC or related publications.
SIGNATURE: ______DATE: ______

Applications must be submitted by 11:59 p.m. Alaska Time on the day of the deadline.

Applications will be considered in the order they were received – first completed, first awarded.

Submit your application and documents to TCF via mail, email, fax, or hand-deliver at:

The CIRI Foundation | 3600 San Jeronimo Drive, Suite 256, Anchorage, AK 99508 | Phone: (907) 793-3575
Toll-free: 1 (800) 764-3382 | Fax: (907) 793-3585 | - 3 -

Applications must be submitted by 11:59 p.m. Alaska Time on the day of the deadline.

Applications will be considered in the order they were received – first completed, first awarded.

Submit your application and documents to TCF via mail, email, fax, or hand-deliver at:

The CIRI Foundation | 3600 San Jeronimo Drive, Suite 256, Anchorage, AK 99508 | Phone: (907) 793-3575
Toll-free: 1 (800) 764-3382 | Fax: (907) 793-3585 | - 5 -

/ Alyeska Pipeline Service Company

Alaska Native Program Scholarship Awards

2015 (Summer/Fall) - 2016 (Spring) Academic Year

STUDENT INFORMATION RELEASE AND ATTESTATION FORM

Dear Student,

Alyeska Pipeline Service Company’s (APSC) Alaska Native Program has provided scholarship and/or internship funding to the following Awarded Organization: ______Cook Inlet Tribal Council______. This organization has been selected to distribute funding for training and educational opportunities strategically focused in Trans Alaska Pipeline System and oil industry professions. Through this Awarded Organization, it has been determined that you are eligible to receive APSC funding.

The Awarded Organization will administer the program funding and monitor your progress during the period in which the scholarship or internship funds are received. This release form will enable the Awarded Organization to provide information to APSC regarding your progress or other information as requested, such as a current resume with contact information that may be used for purposes of employment or other recruitment efforts.

A condition of receipt of APSC funding requires that you complete this Student Information Release and Attestation Form and submit it along with a current resume, and any other requested documentation, to the Awarded Organization named above.

STUDENT ATTESTATION

I, Student Name: ______consent that the Awarded Organization named above may release information to APSC regarding my progress as a student, now and beyond the period of my scholarship award. This information may include, but is not limited to: official grade transcripts, degree/certification program curriculum and completion dates, personal statements of career goals, and resume.

I understand that if my cumulative GPA falls below 2.5, I will no longer be eligible for APSC program funding.

I understand that I can only receive a maximum of $7,500 of APSC program funding per academic year, which may include scholarship or internship funding received from multiple organizations distributing APSC funds, including the Awarded Organization named above.

I understand that release of this information and attestation is a condition for receipt of scholarship or internship funds. I acknowledge that failure to abide by these requirements will jeopardize potential future APSC funding.

______

Student Signature Date of Signature

______

Printed Name Alaska Native Corporation/Village Affiliation

______

School Name Primary Phone

______

School Address Alternate Phone

______

Home Address Email Address

______

Degree Program Estimated Graduation Date

Applications must be submitted by 11:59 p.m. Alaska Time on the day of the deadline.

Applications will be considered in the order they were received – first completed, first awarded.

Submit your application and documents to TCF via mail, email, fax, or hand-deliver at:

The CIRI Foundation | 3600 San Jeronimo Drive, Suite 256, Anchorage, AK 99508 | Phone: (907) 793-3575
Toll-free: 1 (800) 764-3382 | Fax: (907) 793-3585 | - 8 -

CITC Scholarship Application

Tribal Higher Education (THE) Scholarship Guidelines

Administered by The CIRI Foundation

Equal Employment Opportunity (EEO) Disclosure Form

An Equal Opportunity Employer

7083 Rev. 12 (2/24/2015)

Equal Employment Opportunity Information Name: Last First

Alyeska Pipeline Service Company has an Equal Employment Opportunity/Affirmative Action
Program. You may volunteer to help Alyeska in its efforts to comply with the program’s
reporting requirements by answering the following questions. The information you provide
cannot be used to discriminate against you under State or Federal law.
Gender: Female Male / Birth Place: United States Other ______
Ethnic Background (check all that apply)
White American Indian/Alaska Native* Native Hawaiian/other Pacific Islander
Black or African American Not Applicable (Non- U.S.) Other (please list all):______
Hispanic or Latino Asian ______
*(If you are Alaska Native please complete section below)

Alaska Natives Only

Certificate of Indian Blood (CIB) card? Yes No / CIB Number:
Are you a shareholder of a Native Corporation? Yes No / If yes, which Corporation?
Do you have a Certificate of Enrollment to your Native Corporation? Yes No
If you are not a shareholder, are your parents or grandparents shareholders of a Native Corporation? Yes No
If yes, which Corporation?
Are you enrolled with a Tribal Council? Yes No / Please indicate name of Tribal Council:

Please use the space below to provide any additional information to help determine your EEO status.

7083 Rev. 12 (2/24/2015)

CITC Scholarship Document Checklist

Tribal Higher Education (THE)

Supporting documents may be submitted after the deadline, but applications must be received by TCF on time. TCF does not accept late applications.

Completed and signed CITC Higher Education application

Certificate Degree of Indian Blood (CIB/CDIB) or proof of tribal enrollment

CIRI documentation (voting, CIRI shareholder or direct lineal descendent documentation)

Official transcripts noting cumulative GPA of 2.0 or higher

Acceptance letter or academic program change (must include degree program and major enrolled in at school)

Cook Inlet Region affiliated tribes’ relevant award letters and/or denial letter for tribal funding

Reference letter (from a non-family member)

Current class schedule with credit load

Proof of Selective Service Registration (applies toward males ages 18-25)

Statement of purpose (300 words minimum)

Tuition Statement/ Education Cost Statement

Document Descriptions and Forms for

Tribal Higher Education Scholarship (THE)

· Proof of Alaska Native/American Indian (AN/AI) Blood – Available from the Bureau of Indian Affairs (BIA) office at http://www.bia.gov/WhoWeAre/RegionalOffices/Alaska/ This can be in the form of your Certificate Degree of Indian Blood (CDIB or CIB) or Tribal Enrollment Documentation if that document verifies that you are AN/AI. Only 1st time applicants need to submit.

· CIRI documentation – CIRI shareholders do not need to provide any documentation. TCF can verify your shareholder status. Direct lineal descendants of CIRI shareholders must provide documentation that shows you are a lineal descendant of a CIRI shareholder.

· Documents available from CIRI Shareholder Relations: (907) 263-5100, toll free (800) 764-2474, or via email at . Only 1st time applicants need to submit. Options:

§ A CIRI lineal descendant registration card (plan ahead for processing time)

§ Birth certificates and any name change documents that link you to a CIRI shareholder

§ A letter from CIRI Shareholder Relations that states you are a lineal descendent of a CIRI shareholder

· Most current official transcript noting cumulative GPA (you must have and maintain a minimum cumulative GPA of 2.0 to apply and be eligible for the Tribal Higher Education Scholarship). Available from your school’s Office of the Registrar. TCF will accept your unofficial transcripts in-person only, if it is printed, witnessed, and signed by a TCF employee. If college transcripts are not yet applicable, high school transcripts may be provided.