<table>
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<col style="width: 1%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="22"><strong>CANDIDATE CONTROL FORM</strong></td>
<td colspan="16"><em>Please type or print, using black or blue
ink.</em></td>
<td colspan="12">STATE OF LEGAL RESIDENCE</td>
<td>  </td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td><strong>1.</strong></td>
<td colspan="6">Legal name</td>
<td colspan="5">     </td>
<td colspan="17">     </td>
<td colspan="5">  </td>
<td colspan="15">     </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="51"><em>Title First MI Last Suffix</em></td>
</tr>
<tr class="odd">
<td colspan="11">Permanent address 1</td>
<td colspan="31">     </td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td colspan="42"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td colspan="11">Permanent address 2</td>
<td colspan="31">     </td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="2">City</td>
<td colspan="25">     </td>
<td colspan="5">State</td>
<td colspan="4">  </td>
<td colspan="7">ZIP Code</td>
<td colspan="5">     </td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="5">Province</td>
<td colspan="14">     </td>
<td colspan="5">Country</td>
<td colspan="18">     </td>
<td colspan="4">Foreign ZIP</td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="4"><strong>2.</strong> Gender</td>
<td colspan="34"> M F</td>
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="51"><strong>3.</strong> Do you attend school in a state or
country other than your state of legal residence? If so, please
enter:</td>
</tr>
<tr class="even">
<td colspan="16">State/country of school attendance</td>
<td colspan="21">     </td>
<td colspan="14"></td>
</tr>
<tr class="odd">
<td colspan="51"></td>
</tr>
<tr class="even">
<td colspan="37"><strong>4.</strong> Do you live outside of the 50
United States, District of Columbia, or Puerto Rico?</td>
<td colspan="3"> Yes</td>
<td colspan="11"> No</td>
</tr>
<tr class="odd">
<td colspan="22">If so, how long have you lived in this location?</td>
<td colspan="15">     </td>
<td colspan="14"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="2"><img src="media/image1.png"
style="width:0.36944in;height:0.36944in" /></td>
<td colspan="49"><blockquote>
<p><strong>If your state of legal residence and permanent address
differ, or you answered yes to either 3 or 4, call 319/341-2777 or email
PSP@act.org before continuing. This may affect your status as a
candidate for the program.</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="6"><strong>5.</strong> Telephone</td>
<td colspan="11">(     )     -     </td>
<td colspan="11">Foreign phone</td>
<td colspan="11">     </td>
<td colspan="12"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>6.</strong> DOB</td>
<td colspan="11">   /    /     </td>
<td colspan="4">Age</td>
<td colspan="5">  </td>
<td colspan="8"><strong>7.</strong> SSN</td>
<td colspan="9">    -    -     </td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="51"><strong>8.</strong> Contact information where you can
be reached until <mark>June</mark> 22, if different from those provided
above:</td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="10">Mailing address 1</td>
<td colspan="30">     </td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="40"></td>
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="10">Mailing address 2</td>
<td colspan="30">     </td>
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="2">City</td>
<td colspan="25">     </td>
<td colspan="5">State</td>
<td colspan="4">  </td>
<td colspan="7">ZIP Code</td>
<td colspan="5">     </td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="5">Province</td>
<td colspan="14">     </td>
<td colspan="6">Country</td>
<td colspan="16">     </td>
<td colspan="5">Foreign ZIP</td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="3">Phone</td>
<td colspan="10">(   )     -     </td>
<td colspan="8">Foreign phone</td>
<td colspan="14">     </td>
<td colspan="16"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="3"><strong>9.</strong> E-mail</td>
<td colspan="48"><p>     </p>
<p>     </p></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="12"><strong>10.</strong> High school</td>
<td colspan="32">     </td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="12">High school address 1</td>
<td colspan="32">     </td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="44"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="12">High school address 2</td>
<td colspan="32">     </td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="2">City</td>
<td colspan="25">     </td>
<td colspan="5">State</td>
<td colspan="4">  </td>
<td colspan="7">ZIP Code</td>
<td colspan="5">     </td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="51"><strong>11.</strong> On the line below,
<strong>print</strong> your informal name (including your last name) as
you would want it to appear on a name tag. Consider how you would want
to be addressed by fellow Presidential Scholars.</td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="8"></td>
<td></td>
<td colspan="12">     </td>
<td colspan="5">  </td>
<td colspan="19">     </td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="51"><em>First MI Last Suffix</em></td>
</tr>
<tr class="odd">
<td colspan="51"><strong>12.</strong> On the line below,
<strong>print</strong> your name as you would want it to appear on a
Presidential Scholar medallion. This information <strong>cannot</strong>
be revised at a later date.</td>
</tr>
<tr class="even">
<td colspan="8"></td>
<td></td>
<td colspan="11">     </td>
<td colspan="13">     </td>
<td colspan="14">     </td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="51"><em>First Middle Last Suffix</em></td>
</tr>
<tr class="even">
<td colspan="51"><strong>13.</strong> Name the educator who has
influenced you most significantly during your school years and whom you
would like honored. This information should be the same as that provided
on page 6 of your Supporting Information Form.</td>
</tr>
<tr class="odd">
<td colspan="9">Teacher name</td>
<td colspan="4">     </td>
<td colspan="13">     </td>
<td colspan="4">  </td>
<td colspan="15">     </td>
<td colspan="6">     </td>
</tr>
<tr class="even">
<td colspan="51"><em>Title First MI Last Suffix</em></td>
</tr>
<tr class="odd">
<td colspan="10">Teacher school</td>
<td colspan="35">     </td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="14">Teacher school address 1</td>
<td colspan="31">     </td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="45"></td>
<td colspan="6"></td>
</tr>
<tr class="odd">
<td colspan="14">Teacher school address 2</td>
<td colspan="31">     </td>
<td colspan="6"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="2">City</td>
<td colspan="25">     </td>
<td colspan="5">State</td>
<td colspan="4">  </td>
<td colspan="7">ZIP Code</td>
<td colspan="5">     </td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="15">Teacher’s primary subject area</td>
<td colspan="28">     </td>
<td colspan="8"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="10">Teacher address 1</td>
<td colspan="31">     </td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="41"></td>
<td colspan="10"></td>
</tr>
<tr class="odd">
<td colspan="10">Teacher address 2</td>
<td colspan="31">     </td>
<td colspan="10"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="2">City</td>
<td colspan="25">     </td>
<td colspan="5">State</td>
<td colspan="4">  </td>
<td colspan="7">ZIP Code</td>
<td colspan="5">     </td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="51"></td>
</tr>
<tr class="odd">
<td colspan="5">Province</td>
<td colspan="14">     </td>
<td colspan="6">Country</td>
<td colspan="16">     </td>
<td colspan="5">Foreign ZIP</td>
<td colspan="5">     </td>
</tr>
<tr class="even">
<td colspan="29"></td>
<td colspan="22"><mark>OMB No. 1860-0504 – Approved for use through
10/31/2006</mark></td>
</tr>
</tbody>
</table>

SUPPORTING INFORMATION FOR THE

[2007]{.mark} PRESIDENTIAL SCHOLARS PROGRAM

+-----------------------------------------------------------------------+
| # **PRIVACY ACT ADVISORY STATEMENT**                                  |
|                                                                       |
| The Privacy Act of 1974 (P.L. 93-579) requires that you be given      |
| certain information in connection with this request for information.  |
| Accordingly, pursuant to the requirements for the Act, please be      |
| advised:                                                              |
|                                                                       |
| 1.  The authority for the collection of these data is Executive Order |
|     11155.                                                            |
|                                                                       |
| 2.  Furnishing the information requested is voluntary.                |
|                                                                       |
| 3.  The data will be used for selection of Presidential Scholars,     |
|     engraving of Scholar medallions, and arranging transportation and |
|     accommodations for Scholars.                                      |
|                                                                       |
| 4.  Other routine uses of the data are for preparation of the         |
|     Presidential Scholars Yearbook, public affairs, and press         |
|     releases to new media.                                            |
|                                                                       |
| 5.  Failure to complete the form will mean that you cannot be         |
|     included among those candidates being considered for designation  |
|     as Presidential Scholar.                                          |
+-----------------------------------------------------------------------+

# **AFFIRMATION OF CANDIDACY**

## **AND AUTHORIZATION FOR RELEASE OF INFORMATION**

  -------------- ------- ----------- ----------- ---------- -- ----------- --- -------------- -- ----------------------------
  I,                                                                       ,   understand        
                                                                               that I am a       
                                                                               candidate for     
                                                                               the honor of      
                                                                               Presidential      

  Scholar, have                                                                                  
  read the                                                                                       
  Privacy Act                                                                                    
  Advisory                                                                                       
  Statement, and                                                                                 
  affirm my wish                                                                                 
  to be                                                                                          
  considered. In                                                                                 
  the event I am                                                                                 
  named a                                                                                        
  Presidential                                                                                   
  Scholar,                                                                                       
  permission is                                                                                  
  hereby given                                                                                   
  for the                                                                                        
  release of                                                                                     
  materials                                                                                      
  submitted by                                                                                   
  me for the use                                                                                 
  of the                                                                                         
  Commission on                                                                                  
  Presidential                                                                                   
  Scholars and                                                                                   
  the Department                                                                                 
  of Education                                                                                   
  as may be                                                                                      
  deemed                                                                                         
  appropriate                                                                                    
  for purposes                                                                                   
  of the                                                                                         
  Presidential                                                                                   
  Scholars                                                                                       
  Program. I                                                                                     
  further                                                                                        
  consent to the                                                                                 
  release of                                                                                     
  photographs                                                                                    
  which may be                                                                                   
  taken of me,                                                                                   
  by or for the                                                                                  
  U.S.                                                                                           
  Department of                                                                                  
  Education                                                                                      

  in connection                                                unwilling                         to appear on radio and/or
  with the                                                                                       television if such
  Program. I am                                                                                  
  (check one)                                                                                    
  willing lling                                                                                  

  arrangements                                                                                   
  can be made by                                                                                 
  the U.S.                                                                                       
  Department of                                                                                  
  Education in                                                                                   
  connection                                                                                     
  with the                                                                                       
  Presidential                                                                                   
  Scholars                                                                                       
  Program.                                                                                       

  Date                               Signature                                                   
  -------------- ------- ----------- ----------- ---------- -- ----------- --- -------------- -- ----------------------------

## **[CANDIDATE'S BIOGRAPHICAL QUESTIONNAIRE]{.mark}** 

+-----------------------------------------------------------------------+
| > **Note:** The selection of award recipients will be influenced by   |
| > the completeness, neatness, and legibility of replies. **Please     |
| > type or print, in black or blue ink. Font size must be 11 points or |
| > larger. Confine your answers to the space provided; do not attach   |
| > additional pages.**                                                 |
+-----------------------------------------------------------------------+

  ----------------------- ------------ ------------ ------------ ----------- ------------ ------------ ------------ ----------- ---------------- ------------ ------------ ---------------- ------------ ------------ ----------- ------------ ------------ ---------------- ----------- ------------ ------------ ----------- ------------ ---------------- ----------- ------------ ------------ ------------- ---------------- ---------------- -------------- ------------
  **[A. Biographical                                                                                                                                                                                                                                                                                                                                                                                                                                              
  Information]{.mark}**                                                                                                                                                                                                                                                                                                                                                                                                                                           

  [M]{.mark} []{.mark}                                                                                                                                                                                                                                                                                                                                                                                                                                            

  [Legal name in full                                                                                                                                                      [     ]{.mark}                                                                                                                                                   [     ]{.mark}                                                                        [     ]{.mark}   [Sex]{.mark}   
  (Print/Type)]{.mark}                                                                                                                                                                                                                                                                                                                                                                                                                                            

  [*Last First                                                                                                                                                                                                                                                                                                                                                                                                                                                    [F]{.mark}
  MI*]{.mark}                                                                                                                                                                                                                                                                                                                                                                                                                                                     []{.mark}

  [Permanent home                                                                                                               [     ]{.mark}                                                                                                              [     ]{.mark}                                                                                                                         [  ]{.mark}   [     ]{.mark}                                   
  address]{.mark}                                                                                                                                                                                                                                                                                                                                                                                                                                                 

  [*Number and Street*                                                                                                                                                                                                                                                                                                                                                                                                                                            
  *City or Town State ZIP                                                                                                                                                                                                                                                                                                                                                                                                                                         
  Code*]{.mark}                                                                                                                                                                                                                                                                                                                                                                                                                                                   

  [Telephone Date of                                                                                                                                                                                                                                                                                                                                                                                                                                              
  birth Age]{.mark}                                                                                                                                                                                                                                                                                                                                                                                                                                               

  []{.mark}               [ ]{.mark}   [ ]{.mark}   [ ]{.mark}   []{.mark}   [ ]{.mark}   [ ]{.mark}   [ ]{.mark}   []{.mark}                    [ ]{.mark}   [ ]{.mark}                    [ ]{.mark}   [ ]{.mark}   []{.mark}   [ ]{.mark}   [ ]{.mark}                    []{.mark}   [ ]{.mark}   [ ]{.mark}   []{.mark}   [ ]{.mark}   [ ]{.mark}       []{.mark}   [ ]{.mark}   [ ]{.mark}   []{.mark}                                                      
  ----------------------- ------------ ------------ ------------ ----------- ------------ ------------ ------------ ----------- ---------------- ------------ ------------ ---------------- ------------ ------------ ----------- ------------ ------------ ---------------- ----------- ------------ ------------ ----------- ------------ ---------------- ----------- ------------ ------------ ------------- ---------------- ---------------- -------------- ------------

+-----------------------------------------------------------------------+
| #### Paperwork Burden Statement                                       |
|                                                                       |
| According to the Paperwork Reduction Act of 1995, no persons are      |
| required to respond to a collection of information unless such        |
| collection displays a valid OMB control number. The valid OMB control |
| number for this information collection is **[1860-0504]{.mark}**. The |
| time required to complete this information collection is estimated to |
| average 16 hours per response, including the time to review           |
| instructions, search existing data resources, gather the data needed, |
| and complete and review the information collection. **If you have any |
| comments concerning the accuracy of the time estimate or suggestions  |
| for improving this form, please write to:** U.S. Department of        |
| Education, Washington, D.C. 20202-4651. **If you have comments or     |
| concerns regarding the status of your individual submission of this   |
| form, write directly to Presidential Scholars Program, U.S.           |
| Department of Education, 400 Maryland Avenue SW, Washington, D.C.     |
| 20202-3521. Approved for use through [10/31/06]{.mark}.**             |
+-----------------------------------------------------------------------+

<table style="width:100%;">
<colgroup>
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 7%" />
<col style="width: 3%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 3%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="32"><h3 id="section"></h3></td>
</tr>
<tr class="even">
<td colspan="32"><h3 id="b.-education">B. Education</h3></td>
</tr>
<tr class="odd">
<td colspan="32"><h3 id="section-1"></h3></td>
</tr>
<tr class="even">
<td colspan="10"><ol type="1">
<li><p>Name of high school currently attending</p></li>
</ol></td>
<td colspan="22">     </td>
</tr>
<tr class="odd">
<td colspan="32"></td>
</tr>
<tr class="even">
<td colspan="2">City</td>
<td colspan="7">     </td>
<td colspan="5">State<mark>/Country</mark></td>
<td colspan="9">  </td>
<td colspan="4">ZIP Code</td>
<td colspan="5"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="32"></td>
</tr>
<tr class="even">
<td colspan="6">SAT: Verbal/Critical Reading</td>
<td colspan="4">   </td>
<td colspan="3">Math</td>
<td colspan="3">   </td>
<td colspan="2"></td>
<td colspan="3">Writing</td>
<td colspan="3">   </td>
<td colspan="4">Test Date</td>
<td colspan="3">     </td>
<td></td>
</tr>
<tr class="odd">
<td colspan="32"></td>
</tr>
<tr class="even">
<td colspan="3"><blockquote>
<p>ACT: English</p>
</blockquote></td>
<td>  </td>
<td>Math</td>
<td colspan="2">  </td>
<td colspan="4">Reading</td>
<td>  </td>
<td colspan="3">Science</td>
<td colspan="2">  </td>
<td colspan="3">Writing</td>
<td colspan="2">  </td>
<td colspan="3"><mark>Composite</mark></td>
<td>  </td>
<td colspan="3">Test Date</td>
<td colspan="3">     </td>
</tr>
<tr class="odd">
<td colspan="32"></td>
</tr>
<tr class="even">
<td colspan="32"><ol start="2" type="1">
<li><p>List any other schools that you attended in the last four years
in order of attendance, with the most recent one first.</p></li>
</ol></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">Name of school</td>
<td colspan="11">Location (city and state)</td>
<td colspan="11">Dates of attendance</td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="7">     </td>
<td colspan="11">     </td>
<td colspan="11">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="7">     </td>
<td colspan="11">     </td>
<td colspan="11">     </td>
<td colspan="2"></td>
</tr>
</tbody>
</table>

+---+----------------+----------------+-------------+--------+-------+---+
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| P |                |                |             |        |       |   |
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| o |                |                |             |        |       |   |
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| r |                |                |             |        |       |   |
| s |                |                |             |        |       |   |
|   |                |                |             |        |       |   |
|   |                |                |             |        |       |   |
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| o |                |                |             |        |       |   |
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|   |                |                |             |        |       |   |
|   |                |                |             |        |       |   |
|   |                |                |             |        |       |   |
|   |                |                |             |        |       |   |
| h |                |                |             |        |       |   |
| e |                |                |             |        |       |   |
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| . |                |                |             |        |       |   |
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| * |                |                |             |        |       |   |
+---+----------------+----------------+-------------+--------+-------+---+
|   | Course or      | Name of school | Location    | Dates  | Hours |   |
|   | program        |                | (city and   | of     | per   |   |
|   |                |                | state)      | atte   | week  |   |
|   |                |                |             | ndance |       |   |
+---+----------------+----------------+-------------+--------+-------+---+
|   |                |                |             |        |       |   |
+---+----------------+----------------+-------------+--------+-------+---+
|   |                |                |             |        |       |   |
+---+----------------+----------------+-------------+--------+-------+---+

<table>
<colgroup>
<col style="width: 10%" />
<col style="width: 10%" />
<col style="width: 16%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 5%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 20%" />
<col style="width: 14%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="5"><ol start="4" type="1">
<li><p>Name of first-choice college or university</p></li>
</ol></td>
<td colspan="9">     </td>
</tr>
<tr class="even">
<td colspan="14"></td>
</tr>
<tr class="odd">
<td>City</td>
<td colspan="9">     </td>
<td></td>
<td>State</td>
<td colspan="2">  </td>
</tr>
<tr class="even">
<td colspan="10"><ol start="5" type="1">
<li><p>What course of study (major) would you like to pursue in college?
(You may indicate more than one or answer “undecided.”)</p></li>
</ol></td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="7"><ol start="6" type="1">
<li><p>Do you plan to go to graduate or professional school?</p></li>
</ol></td>
<td colspan="7">   </td>
</tr>
<tr class="even">
<td colspan="3"><ol start="7" type="1">
<li><p>Have you made any career decisions?</p></li>
</ol></td>
<td></td>
<td colspan="2">Yes</td>
<td colspan="2"></td>
<td>No</td>
<td colspan="4"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">If <strong>yes</strong>, specify:</td>
<td colspan="12">     </td>
</tr>
</tbody>
</table>

+---+-----------------+---------+------+---------------+---------------+
| # |                 |         |      |               |               |
| # |                 |         |      |               |               |
| # |                 |         |      |               |               |
|   |                 |         |      |               |               |
| C |                 |         |      |               |               |
| . |                 |         |      |               |               |
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| v |                 |         |      |               |               |
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| t |                 |         |      |               |               |
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| s |                 |         |      |               |               |
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| u |                 |         |      |               |               |
|   |                 |         |      |               |               |
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|   |                 |         |      |               |               |
|   |                 |         |      |               |               |
| c |                 |         |      |               |               |
| o |                 |         |      |               |               |
| n |                 |         |      |               |               |
| s |                 |         |      |               |               |
| i |                 |         |      |               |               |
| d |                 |         |      |               |               |
| e |                 |         |      |               |               |
| r |                 |         |      |               |               |
|   |                 |         |      |               |               |
|   |                 |         |      |               |               |
|   |                 |         |      |               |               |
|   |                 |         |      |               |               |
| m |                 |         |      |               |               |
| o |                 |         |      |               |               |
| s |                 |         |      |               |               |
| t |                 |         |      |               |               |
|   |                 |         |      |               |               |
|   |                 |         |      |               |               |
|   |                 |         |      |               |               |
|   |                 |         |      |               |               |
| i |                 |         |      |               |               |
| m |                 |         |      |               |               |
| p |                 |         |      |               |               |
| o |                 |         |      |               |               |
| r |                 |         |      |               |               |
| t |                 |         |      |               |               |
| a |                 |         |      |               |               |
| n |                 |         |      |               |               |
| t |                 |         |      |               |               |
| . |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   | Activity        | Dates   | H    | Offices held  | Special       |
|   |                 | of      | ours |               | awards or     |
|   |                 | partic  | per  |               | honors        |
|   |                 | ipation | week |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
|   |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+
| [ |                 |         |      |               |               |
| O |                 |         |      |               |               |
| M |                 |         |      |               |               |
| B |                 |         |      |               |               |
| N |                 |         |      |               |               |
| o |                 |         |      |               |               |
| . |                 |         |      |               |               |
| 1 |                 |         |      |               |               |
| 8 |                 |         |      |               |               |
| 6 |                 |         |      |               |               |
| 0 |                 |         |      |               |               |
| - |                 |         |      |               |               |
| 0 |                 |         |      |               |               |
| 5 |                 |         |      |               |               |
| 0 |                 |         |      |               |               |
| 4 |                 |         |      |               |               |
| ] |                 |         |      |               |               |
| { |                 |         |      |               |               |
| . |                 |         |      |               |               |
| m |                 |         |      |               |               |
| a |                 |         |      |               |               |
| r |                 |         |      |               |               |
| k |                 |         |      |               |               |
| } |                 |         |      |               |               |
|   |                 |         |      |               |               |
| [ |                 |         |      |               |               |
| A |                 |         |      |               |               |
| p |                 |         |      |               |               |
| p |                 |         |      |               |               |
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| d |                 |         |      |               |               |
| f |                 |         |      |               |               |
| o |                 |         |      |               |               |
| r |                 |         |      |               |               |
| u |                 |         |      |               |               |
| s |                 |         |      |               |               |
| e |                 |         |      |               |               |
| t |                 |         |      |               |               |
| h |                 |         |      |               |               |
| r |                 |         |      |               |               |
| o |                 |         |      |               |               |
| u |                 |         |      |               |               |
| g |                 |         |      |               |               |
| h |                 |         |      |               |               |
| 1 |                 |         |      |               |               |
| 0 |                 |         |      |               |               |
| / |                 |         |      |               |               |
| 3 |                 |         |      |               |               |
| 1 |                 |         |      |               |               |
| / |                 |         |      |               |               |
| 0 |                 |         |      |               |               |
| 6 |                 |         |      |               |               |
| ] |                 |         |      |               |               |
| { |                 |         |      |               |               |
| . |                 |         |      |               |               |
| m |                 |         |      |               |               |
| a |                 |         |      |               |               |
| r |                 |         |      |               |               |
| k |                 |         |      |               |               |
| } |                 |         |      |               |               |
+---+-----------------+---------+------+---------------+---------------+

+----------------------------------------------+-----------------------+
| Name (Print/Type)                            |                       |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| 2.  List any **special talents** (in areas   |                       |
|     such as music, the arts, sports,         |                       |
|     published writing or scientific          |                       |
|     research) that you pursue                |                       |
|                                              |                       |
| **outside of school.**                       |                       |
+----------------------------------------------+-----------------------+

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 20%" />
<col style="width: 4%" />
<col style="width: 7%" />
<col style="width: 13%" />
<col style="width: 8%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 8%" />
<col style="width: 6%" />
<col style="width: 15%" />
</colgroup>
<tbody>
<tr class="odd">
<td></td>
<td colspan="2">Talent or activity</td>
<td colspan="3">Periods of participation</td>
<td colspan="7">Special honors, recognition, or awards</td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2">     </td>
<td colspan="3">     </td>
<td colspan="7">     </td>
</tr>
<tr class="even">
<td colspan="13"></td>
</tr>
<tr class="odd">
<td colspan="13"><ol start="3" type="1">
<li><p>List <strong>community activities</strong> in which you have
participated without pay (such as hospital volunteer, religious work,
drug/teen/homework hotlines, or outreach programs).</p></li>
</ol></td>
</tr>
<tr class="even">
<td></td>
<td>Type of work</td>
<td colspan="3">Name of agency or organization</td>
<td colspan="4">Dates of participation</td>
<td colspan="2">Hours per week</td>
<td colspan="2">Special awards</td>
</tr>
<tr class="odd">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="even">
<td></td>
<td>     </td>
<td colspan="3">     </td>
<td colspan="4">     </td>
<td colspan="2">   </td>
<td colspan="2">     </td>
</tr>
<tr class="odd">
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="13"><ol start="4" type="1">
<li><p>List <strong>jobs</strong> you have held in the past three or
four years.</p></li>
</ol></td>
</tr>
<tr class="odd">
<td rowspan="2"></td>
<td colspan="3" rowspan="2">Job and type of work</td>
<td colspan="3" rowspan="2">Employer</td>
<td colspan="3"><em>Check one:</em></td>
<td colspan="2" rowspan="2">Approximate dates of employment</td>
<td rowspan="2"><p>Approximate number of hours</p>
<p>per week</p></td>
</tr>
<tr class="even">
<td>Sum-mer</td>
<td colspan="2">School year</td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="odd">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="even">
<td></td>
<td colspan="3">     </td>
<td colspan="3">     </td>
<td> </td>
<td colspan="2"> </td>
<td colspan="2">     </td>
<td>   </td>
</tr>
<tr class="odd">
<td colspan="13"></td>
</tr>
<tr class="even">
<td colspan="13"><p><mark>OMB No. 1860-0504</mark></p>
<p><mark>Approved for use through 10/31/06</mark></p></td>
</tr>
</tbody>
</table>

<table>
<colgroup>
<col style="width: 17%" />
<col style="width: 0%" />
<col style="width: 9%" />
<col style="width: 0%" />
<col style="width: 19%" />
<col style="width: 13%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 12%" />
<col style="width: 15%" />
<col style="width: 1%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="11"><strong>Note: Please be concise. Limit your responses
to the spaces provided. Feel welcome to word-process your responses and
then paste them on this form. Font size must be 11 points or larger. Do
not attach additional pages.</strong></td>
</tr>
<tr class="even">
<td colspan="11"><strong>D. Candidate’s Self Assessment</strong></td>
</tr>
<tr class="odd">
<td colspan="11"><ol type="1">
<li><p>Describe any characteristics of your family or your community
that have been important to your personal development.</p></li>
</ol>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="11"><ol start="2" type="1">
<li><p>Discuss some creative work that illustrates the way you see the
world and the way you see yourself in the world. The work may be a
scientific theory, novel, film, poem, song, or other art form.</p></li>
</ol>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="11"><p><mark>OMB No. 1860-0504</mark></p>
<p><mark>Approved for use through 10/31/06</mark></p></td>
</tr>
<tr class="even">
<td colspan="7">Name (Print/Type)</td>
<td colspan="4">     </td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="11"><ol start="3" type="1">
<li><p>What is the most significant contribution that you feel you have
made to your community’s well-being or the well-being of an individual
or individuals in your community? Why were you motivated to do this?
What effect do you think it has had on that person or the
community?</p></li>
</ol>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="11"><ol start="4" type="1">
<li><p>Describe a mistake you made or a challenge you faced. How did you
respond to that mistake or challenge, and what did you learn from your
experience?</p></li>
</ol>
<blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="11"><p><mark>OMB No. 1860-0504</mark></p>
<p><mark>Approved for use through 10/31/0</mark>6</p></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="11"><strong>E.</strong> Name the teacher or instructor who
has influenced you most significantly during your school years and whom
you would like honored. (Note: Should you become a Presidential Scholar,
the teacher you name will be invited to Washington, D.C., and honored
for his or her accomplishments. Please be sure to print or type the
teacher’s name clearly.)</td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td>Teacher’s name</td>
<td colspan="2">     </td>
<td colspan="2">     </td>
<td>     </td>
<td colspan="4">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><em>Title (Mr., Ms.) First Middle Initial
Last</em></td>
</tr>
<tr class="odd">
<td colspan="2">Teacher’s school</td>
<td colspan="8">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><em>Name</em></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">     </td>
<td>  </td>
<td>     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"><h5 id="city-state-zip-code"> City State ZIP code
</h5></td>
</tr>
<tr class="odd">
<td colspan="4">Teacher’s primary subject area</td>
<td colspan="6">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="11"></td>
</tr>
<tr class="odd">
<td colspan="11"><blockquote>
<p>Explain the reason for your selection.</p>
<p>     </p>
</blockquote></td>
</tr>
</tbody>
</table>

+---+---------------+---+----+-----------------------------------------+---+
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+---+---------------+---+----+-----------------------------------------+---+
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+---+---------------+---+----+-----------------------------------------+---+
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+---+---------------+---+----+-----------------------------------------+---+
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| k |               |   |    |                                         |   |
| } |               |   |    |                                         |   |
| * |               |   |    |                                         |   |
| * |               |   |    |                                         |   |
+---+---------------+---+----+-----------------------------------------+---+
| [ |               |   |    |                                         |   |
| O |               |   |    |                                         |   |
| M |               |   |    |                                         |   |
| B |               |   |    |                                         |   |
| N |               |   |    |                                         |   |
| o |               |   |    |                                         |   |
| . |               |   |    |                                         |   |
| 1 |               |   |    |                                         |   |
| 8 |               |   |    |                                         |   |
| 6 |               |   |    |                                         |   |
| 0 |               |   |    |                                         |   |
| - |               |   |    |                                         |   |
| 0 |               |   |    |                                         |   |
| 5 |               |   |    |                                         |   |
| 0 |               |   |    |                                         |   |
| 4 |               |   |    |                                         |   |
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| a |               |   |    |                                         |   |
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| } |               |   |    |                                         |   |
|   |               |   |    |                                         |   |
| [ |               |   |    |                                         |   |
| A |               |   |    |                                         |   |
| p |               |   |    |                                         |   |
| p |               |   |    |                                         |   |
| r |               |   |    |                                         |   |
| o |               |   |    |                                         |   |
| v |               |   |    |                                         |   |
| e |               |   |    |                                         |   |
| d |               |   |    |                                         |   |
| f |               |   |    |                                         |   |
| o |               |   |    |                                         |   |
| r |               |   |    |                                         |   |
| u |               |   |    |                                         |   |
| s |               |   |    |                                         |   |
| e |               |   |    |                                         |   |
| t |               |   |    |                                         |   |
| h |               |   |    |                                         |   |
| r |               |   |    |                                         |   |
| o |               |   |    |                                         |   |
| u |               |   |    |                                         |   |
| g |               |   |    |                                         |   |
| h |               |   |    |                                         |   |
| 1 |               |   |    |                                         |   |
| 0 |               |   |    |                                         |   |
| / |               |   |    |                                         |   |
| 3 |               |   |    |                                         |   |
| 1 |               |   |    |                                         |   |
| / |               |   |    |                                         |   |
| 0 |               |   |    |                                         |   |
| 6 |               |   |    |                                         |   |
| ] |               |   |    |                                         |   |
| { |               |   |    |                                         |   |
| . |               |   |    |                                         |   |
| m |               |   |    |                                         |   |
| a |               |   |    |                                         |   |
| r |               |   |    |                                         |   |
| k |               |   |    |                                         |   |
| } |               |   |    |                                         |   |
+---+---------------+---+----+-----------------------------------------+---+

# **CANDIDATE ESSAY**

+----+--------------------------------------------+---+---+------------+
| Na |                                            |   | S |            |
| me |                                            |   | t |            |
|    |                                            |   | a |            |
|    |                                            |   | t |            |
|    |                                            |   | e |            |
+----+--------------------------------------------+---+---+------------+
|    |                                            |   |   |            |
+----+--------------------------------------------+---+---+------------+
| ** |                                            |   |   |            |
| To |                                            |   |   |            |
| pi |                                            |   |   |            |
| c: |                                            |   |   |            |
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| ta |                                            |   |   |            |
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| a  |                                            |   |   |            |
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| of |                                            |   |   |            |
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| d, |                                            |   |   |            |
| pl |                                            |   |   |            |
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+----+--------------------------------------------+---+---+------------+
| >  |                                            |   |   |            |
|    |                                            |   |   |            |
|    |                                            |   |   |            |
|    |                                            |   |   |            |
+----+--------------------------------------------+---+---+------------+
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| 06 |                                            |   |   |            |
| ]{ |                                            |   |   |            |
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+----+--------------------------------------------+---+---+------------+
|    |                                            |   |   |            |
+----+--------------------------------------------+---+---+------------+
| >  |                                            |   |   |            |
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| >  |                                            |   |   |            |
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| >  |                                            |   |   |            |
| 10 |                                            |   |   |            |
| /3 |                                            |   |   |            |
| 1/ |                                            |   |   |            |
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| k} |                                            |   |   |            |
+----+--------------------------------------------+---+---+------------+

PRESIDENTIAL SCHOLARS PROGRAM

VOLUNTARY SURVEY FORM

<table>
<colgroup>
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 0%" />
<col style="width: 35%" />
<col style="width: 21%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 19%" />
<col style="width: 0%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="10"><p>The following information is requested on a
voluntary basis. The information</p>
<p>will be used for statistical purposes only and will remain
confidential. Check</p>
<p>the box(es) next to the race/ethnicity with which you most closely
identify.</p>
<p>You may choose all that apply.</p></td>
</tr>
<tr class="even">
<td colspan="10"></td>
</tr>
<tr class="odd">
<td><h1 id="section-2"></h1></td>
<td colspan="2"><h1 id="section-3"></h1></td>
<td colspan="6"><h1 id="american-indian-or-alaska-native">
<strong>American Indian or Alaska Native</strong></h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-4"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1
id="a-person-having-origins-in-any-of-the-original-peoples-of">A person
having origins in any of the original peoples of</h1>
<h1 id="north-and-south-america-including-central-america-and">North and
South America (including Central America), and</h1>
<h1 id="who-maintains-tribal-affiliation-or-community-attachment.">who
maintains tribal affiliation or community attachment.</h1></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-5"></h1></td>
</tr>
<tr class="odd">
<td><h1 id="section-6"></h1></td>
<td colspan="2"><h1 id="section-7"></h1></td>
<td colspan="6"><h1 id="asian"> <strong>Asian</strong> </h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-8"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><p><em>A person having origins in any of the original
peoples of</em></p>
<p><em>the Far East, Southeast Asia, or the Indian subcontinent</em></p>
<p><em>including, for example, Cambodia, China, India, Japan,</em></p>
<p><em>Korea, Malaysia, Pakistan, the Philippine Islands,
Thailand,</em></p>
<p><em>and Vietnam.</em></p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-9"></h1></td>
</tr>
<tr class="odd">
<td><h1 id="section-10"></h1></td>
<td colspan="2"><h1 id="section-11"></h1></td>
<td colspan="6"><h1 id="black-or-african-american"> <strong>Black or
African American</strong></h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-12"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1
id="a-person-having-origins-in-any-of-the-black-racial-groups">A person
having origins in any of the black racial groups</h1>
<h1 id="of-africa.">of Africa.</h1></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-13"></h1></td>
</tr>
<tr class="odd">
<td><h1 id="section-14"></h1></td>
<td colspan="2"><h1 id="section-15"></h1></td>
<td colspan="6"><h1 id="hispanic-or-latino"> <strong>Hispanic or
Latino</strong></h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-16"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1
id="a-person-of-cuban-mexican-puerto-rican-south-or">A person of Cuban,
Mexican, Puerto Rican, South or </h1>
<h1 id="central-american-or-other-spanish-culture-or-origin">Central
American, or other Spanish culture or origin,</h1>
<p><em>regardless of race.</em></p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-17"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"><h1 id="section-18"></h1></td>
<td colspan="2"><h1 id="section-19"></h1></td>
<td colspan="6"><h1 id="native-hawaiian-or-other-pacific-islander">
<strong>Native Hawaiian or Other Pacific Islander</strong></h1></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-20"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><p><em>A person having origins in any of the original
peoples of</em></p>
<p><em>Hawaii, Guam, Samoa, or other Pacific Islands.</em></p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-21"></h1></td>
</tr>
<tr class="odd">
<td><h1 id="section-22"></h1></td>
<td colspan="2"><h1 id="section-23"></h1></td>
<td colspan="6"><h1 id="white"> <strong>White</strong> </h1></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-24"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1
id="a-person-having-origins-in-any-of-the-original-peoples-of-1">A
person having origins in any of the original peoples of</h1>
<p><em>Europe, the Middle East, or North Africa.</em></p></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="section-25"></h1></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="6"><h1 id="yes-no"> Yes No </h1></td>
</tr>
<tr class="even">
<td colspan="6"><h1
id="do-you-consider-yourself-to-be-physically-challenged-or-disabled">Do
you consider yourself to be physically challenged or disabled?</h1></td>
<td><h1 id="section-26"></h1></td>
<td><h1 id="section-27"></h1></td>
<td><h1 id="section-28"></h1></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="10"><h1 id="section-29"></h1></td>
</tr>
<tr class="even">
<td colspan="5"><h1
id="if-so-please-briefly-describe-your-disability">If so, please briefly
describe your disability:</h1></td>
<td colspan="5"><h1 id="section-30"><strong>     </strong></h1></td>
</tr>
<tr class="odd">
<td colspan="10"><h1 id="section-31"> </h1></td>
</tr>
</tbody>
</table>

[OMB No. 1860-0504]{.mark}

[Approved for use through 10/31/06]{.mark}

<table>
<colgroup>
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 6%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 0%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 0%" />
<col style="width: 2%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="49"><h1
id="presidential-scholars-program-1"><strong><mark>2007</mark>
PRESIDENTIAL SCHOLARS PROGRAM</strong></h1></td>
</tr>
<tr class="even">
<td colspan="49"><h1 id="secondary-school-report"><strong>SECONDARY
SCHOOL REPORT</strong></h1></td>
</tr>
<tr class="odd">
<td colspan="49"><h1 id="section-32"></h1></td>
</tr>
<tr class="even">
<td colspan="8"><h1 id="legal-name-of-student"><strong>Legal name of
student</strong></h1></td>
<td colspan="17"><h1 id="section-33">      </h1></td>
<td colspan="16"><h1 id="section-34">     </h1></td>
<td colspan="8"><h1 id="section-35">     </h1></td>
</tr>
<tr class="odd">
<td colspan="7"><h1 id="please-type-or-print-using-black-ink.">Please
type or print, using black ink.</h1></td>
<td colspan="18"><h1 id="last"> Last </h1></td>
<td colspan="15"><h1 id="first"> First</h1></td>
<td colspan="9"><h1 id="mi"> MI </h1></td>
</tr>
<tr class="even">
<td colspan="7"><h1 id="section-36"></h1></td>
<td colspan="30"><h1 id="section-37"></h1></td>
<td colspan="5"><h1 id="section-38"></h1></td>
<td colspan="7"><h1 id="section-39"></h1></td>
</tr>
<tr class="odd">
<td colspan="49"><h1 id="section-40"></h1></td>
</tr>
<tr class="even">
<td colspan="2"><h1 id="section-41"></h1></td>
<td colspan="47"><p>To comply with the provisions of the Family
Educational Rights and Privacy Act of 1974, a school must obtain signed
authorization before it can release student information for use in this
program.</p>
<p>Permission is hereby given to school officials to release the
secondary school record and other requested information for the student
named above for consideration in this award program.</p></td>
</tr>
<tr class="odd">
<td colspan="2"><h1 id="section-42"></h1></td>
<td colspan="4"><h1 id="students-signature">Student’s
signature</h1></td>
<td colspan="33"><h1 id="section-43"></h1></td>
<td colspan="4"><h1 id="date">Date</h1></td>
<td colspan="5"><h1 id="section-44">     </h1></td>
<td><h1 id="section-45"></h1></td>
</tr>
<tr class="even">
<td colspan="2"><h1 id="section-46"></h1></td>
<td colspan="14"><h1 id="parents-or-legal-guardians-signature">Parent’s
or legal guardian’s signature</h1></td>
<td colspan="23"><h1 id="section-47"></h1></td>
<td colspan="4"><h1 id="date-1">Date</h1></td>
<td colspan="5"><h1 id="section-48">     </h1></td>
<td><h1 id="section-49"></h1></td>
</tr>
<tr class="odd">
<td colspan="10"><h1 id="section-50"></h1></td>
<td colspan="27"><h1 id="section-51"></h1></td>
<td colspan="6"><h1 id="section-52"></h1></td>
<td colspan="6"><h1 id="section-53"></h1></td>
</tr>
<tr class="even">
<td colspan="10"><h1 id="section-54"></h1></td>
<td colspan="27"><h1 id="section-55"></h1></td>
<td colspan="6"><h1 id="section-56"></h1></td>
<td colspan="6"><h1 id="section-57"></h1></td>
</tr>
<tr class="odd">
<td colspan="49"><h1
id="if-you-have-attended-this-school-for-less-than-two-years-you-may-copy-this-form-and-request-someone-from-your-former-school-to-also-complete-a-copy-for-you.">If
you have attended this school for less than two years, you may copy this
form and request someone from your former school to also complete a copy
for you<strong>.</strong></h1></td>
</tr>
<tr class="even">
<td colspan="3"><h1 id="school"><strong>School</strong></h1></td>
<td colspan="15"><h1 id="section-58">      </h1></td>
<td colspan="10"><h1 id="section-59">      </h1></td>
<td colspan="3"><h1 id="section-60">   </h1></td>
<td colspan="5"><h1 id="section-61">      </h1></td>
<td colspan="13"><h1 id="section-62">      </h1></td>
</tr>
<tr class="odd">
<td colspan="49"><h1 id="name-city-state-zip-code-telephone"> Name City
State ZIP Code Telephone</h1></td>
</tr>
<tr class="even">
<td colspan="49"><h1
id="important-instructions-for-evaluator-and-principal">
<strong>Important Instructions for Evaluator and
Principal:</strong></h1></td>
</tr>
<tr class="odd">
<td colspan="49"><h1
id="the-student-named-above-is-a-candidate-for-the-honor-of-presidential-scholar.-please-provide-thorough-and-complete-responses-to-the-questions-on-this-form.-incomplete-or-limited-answers-will-place-your-student-at-a-disadvantage.-if-you-complete-this-form-by-hand-please-write-legibly-using-black-or-blue-ink.">The
student named above is a candidate for the honor of Presidential
Scholar. Please provide thorough and complete responses to the questions
on this form. Incomplete or limited answers will place your student at a
disadvantage. If you complete this form by hand, please write legibly
using black or blue ink.</h1>
<h1
id="do-not-submit-a-letter-of-recommendation-as-a-replacement-for-this-form.-all-extraneous-material-including-letters-of-recommendation-are-removed-from-candidates-files-and-will-not-be-included-with-the-application-for-review."><strong>Do
not</strong> submit a letter of recommendation as a replacement for this
form. <strong>All extraneous material, including letters of
recommendation, are removed from candidates’ files and will not be
included with the application for review.</strong></h1>
<h1
id="if-you-submit-a-letter-of-recommendation-your-students-application-will-be-reviewed-as-it-stands-without-the-letter-of-recommendation-placing-your-student-at-a-disadvantage.-if-you-wish-you-may-cutcopy-and-paste-your-answers-to-the-questions-on-this-form-from-a-letter-of-recommendation.">If
you submit a letter of recommendation, your student’s application will
be reviewed as it stands <strong>without the letter of recommendation,
placing your student at a disadvantage.</strong> If you wish, you may
cut/copy and paste your answers to the questions on this form from a
letter of recommendation.</h1>
<h1 id="section-63"></h1>
<h1
id="in-order-to-process-this-students-application-we-must-receive">In
order to process this student’s application, we must receive</h1>
<ul>
<li><p>this completed form;</p></li>
<li><p>a 7-semester secondary school transcript, including grades 9-12,
as well as</p></li>
</ul>
<h2 id="satact-scores-and-any-ap-test-scores-and">SAT/ACT scores and any
AP test scores; and</h2>
<ul>
<li><p>a school profile, if available.</p></li>
</ul>
<ol type="1">
<li><p>Both the evaluator and the principal must sign this form on page
4. Seal the signed form, transcript, test scores, and school profile in
an envelope. A school official’s signature must appear across the
envelope seal for it to be accepted by the Commission.
<em><strong>Return the signed envelope to the student for submission
with his or her application materials, in time to meet the RECEIPT
deadline noted below.</strong></em> If you need assistance with this
requirement, call 319/341-2777 8:30am – 5:00pm Central Time.</p></li>
</ol></td>
</tr>
<tr class="even">
<td colspan="49"><h1
id="all-application-materials-including-this-form-and-transcripts-must-be-received-by-500-p.m.-central-time-february-22-2007.-any-application-materials-not-received-by-that-deadline-will-render-the-students-application-ineligible-for-review-regardless-of-who-sends-them.">All
application materials, including this form and transcripts, must be
received by <strong>5:00 <span class="smallcaps">p.m.</span> Central
Time, February <mark>22, 2007</mark>. Any</strong> application materials
not received by that deadline will render the student’s application
ineligible for review, <strong>regardless of who sends
them.</strong></h1></td>
</tr>
<tr class="odd">
<td colspan="49"><h1 id="omb-no.-1860-0504"> <mark>OMB No.
1860-0504</mark></h1></td>
</tr>
<tr class="even">
<td colspan="49"><h1 id="approved-for-use-through-103106">
<mark>Approved for use through 10/31/06</mark></h1></td>
</tr>
<tr class="odd">
<td colspan="49"><blockquote>
<p><strong>Items A-F should be completed by the Guidance
Office/Counselor or Principal.</strong></p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="9"><strong>A.</strong> Name of principal</td>
<td colspan="18"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="18"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="4"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><h5 id="last-first-mi"> Last First MI</h5></td>
</tr>
<tr class="even">
<td colspan="49"><blockquote>
<p><strong>B.</strong> Are you confident that the student will receive a
school diploma during the current academic year?</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="5"><p>Yes</p></td>
<td colspan="6"><p>No</p></td>
<td colspan="8">If no, please explain.</td>
<td colspan="30"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="13"></td>
<td colspan="8"></td>
<td></td>
<td colspan="7"></td>
<td colspan="20"></td>
</tr>
<tr class="odd">
<td colspan="13"><strong>C</strong>. Expected date of graduation</td>
<td colspan="6"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>/</p>
</blockquote></td>
<td colspan="4"><blockquote>
<p>    </p>
</blockquote></td>
<td colspan="24"></td>
</tr>
<tr class="even">
<td colspan="49"><em>Month Year</em></td>
</tr>
<tr class="odd">
<td colspan="7"><strong>D.</strong> Student’s class rank</td>
<td colspan="8"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="10">Number of students in class</td>
<td colspan="4"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="20"> School does not rank students.</td>
</tr>
<tr class="even">
<td colspan="15"><strong>E.</strong> Student’s grade point average</td>
<td colspan="4"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="3">on a</td>
<td colspan="4"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="9">point scale, based on</td>
<td colspan="3">  </td>
<td colspan="11">semesters.</td>
</tr>
<tr class="odd">
<td colspan="17"><strong>F.</strong> Number of AP courses your school
offers:</td>
<td colspan="5"><blockquote>
<p>   </p>
</blockquote></td>
<td colspan="22"><blockquote>
<p>Number this student will have taken by graduation:</p>
</blockquote></td>
<td colspan="2"><blockquote>
<p>   </p>
</blockquote></td>
<td colspan="3"></td>
</tr>
<tr class="even">
<td colspan="13">AP exams taken and results:</td>
<td colspan="36">     </td>
</tr>
<tr class="odd">
<td colspan="23"><strong>G.</strong> Who is evaluating the student on
the following pages?</td>
<td colspan="26"></td>
</tr>
<tr class="even">
<td colspan="4">Name</td>
<td colspan="20"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="10">Relationship to student</td>
<td colspan="15"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><em>e.g., Teacher/Counselor</em></td>
</tr>
<tr class="even">
<td colspan="9">Length of relationship</td>
<td colspan="11">     </td>
<td colspan="12">If teacher, please state subject(s)</td>
<td colspan="17"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"></td>
</tr>
<tr class="even">
<td colspan="49">In items H-O, please be concise. Use examples to
support your comments. Limit your response to the space provided.</td>
</tr>
<tr class="odd">
<td colspan="49"><blockquote>
<p><strong>H.</strong> What economic or social conditions characterize
your community and most of the parents of the children in your school?
(For example, is your community a university town, a mill town, a
farming area?)</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="49"><p><strong>I.</strong> Considering this student’s
interests, work habits, and life goals, what is your assessment of the
chances that the student</p>
<blockquote>
<p>will be motivated to take advantage of the opportunities available in
college? Please give reasons for your assessment.</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><p>2 <mark>OMB No. 1860-0504</mark></p>
<p><mark>Approved for use through 10/31/06</mark></p></td>
</tr>
<tr class="even">
<td colspan="49"><blockquote>
<p><strong>J.</strong> Does your school have a service requirement? Yes
No If yes, number of hours and type of service required:</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><blockquote>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="49"><blockquote>
<p>This student has exceeded met not met the service requirement.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><blockquote>
<p>What special features are part of your school’s curriculum (e.g. AP
and honors courses, college study, independent study)?</p>
<p>Has the student taken advantage of the most challenging opportunities
your school has to offer?</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="49"><p><strong>K.</strong> Has this student given any
strong evidence of leadership ability? Yes No</p>
<blockquote>
<p>Please explain the criteria on which you base your judgment and how
the student meets those criteria. Include a discussion</p>
<p>of the student’s principal strength.</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><p><strong>L.</strong> Describe how this student
demonstrates strong character (e.g. integrity, independence, loyalty,
patriotism, self-discipline,</p>
<blockquote>
<p>employment responsibilities, willingness to work hard, kindness,
commitment to high ideals, and caring for others).</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="49"><p>3 <mark>OMB No. 1860-0504</mark></p>
<p><mark>Approved for use through 10/31/06</mark></p></td>
</tr>
<tr class="odd">
<td colspan="49"><blockquote>
<p><strong>M.</strong> Has the student shown exceptional talent or
originality in any specific field such as art, music, science,
literature, or mathematics? Yes No Please cite examples.</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="49"><blockquote>
<p><strong>N.</strong> <del>Sometimes special circumstances should be
considered when evaluating a student’s achievement record and test
scores. If in your opinion, this student may be disadvantaged by any
such circumstances, please specify.</del></p>
<p><mark>Is there anything else about this student you feel is important
for the Commission to know that is not likely to appear in the student’s
application or transcript – additional qualities, anecdotes,
circumstances, or background that would give the Commission insight into
this individual?</mark></p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><blockquote>
<p><strong>O.</strong> What areas<mark>, academic or otherwise,</mark>
have most challenged this student?</p>
<p>     </p>
</blockquote></td>
</tr>
<tr class="even">
<td colspan="49"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="11"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="16"></td>
<td colspan="3"></td>
<td colspan="14">     </td>
<td colspan="2"></td>
</tr>
<tr class="even">
<td colspan="12">DATE</td>
<td colspan="18">EVALUATOR’S SIGNATURE</td>
<td colspan="19">TITLE</td>
</tr>
<tr class="odd">
<td colspan="49"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="11"><blockquote>
<p>     </p>
</blockquote></td>
<td colspan="2"></td>
<td colspan="16"></td>
<td colspan="3"></td>
<td colspan="14">     </td>
<td colspan="2"></td>
</tr>
<tr class="odd">
<td colspan="12">DATE</td>
<td colspan="18">PRINCIPAL’S SIGNATURE</td>
<td colspan="19">TITLE</td>
</tr>
<tr class="even">
<td colspan="49"><blockquote>
<p>After completing this form, attach the candidate’s transcript, test
scores, and a copy of your school profile, and seal them all in an
envelope. Sign your name across the seal and <strong>return the envelope
to the student</strong> for submission with his/her application
materials per the deadline noted on Page 1 of this form. If you need
assistance with this requirement, please call 319/341-2777, 8:30am –
5:00pm Central Time.</p>
</blockquote></td>
</tr>
<tr class="odd">
<td colspan="49"><p>4</p>
<p><mark>OMB 1860-0504</mark></p>
<p><mark>Approved for use through 10/31/06</mark></p></td>
</tr>
</tbody>
</table>