CANDIDATE CONTROL FORM Please type or print, using black or blue ink. STATE OF LEGAL RESIDENCE

1. Legal name Title First MI Last Suffix 

Permanent address 1 

Permanent address 2 

City State ZIP Code+4 

Province Country Foreign ZIP 

2. Gender Male Female 

3. Do you attend school in a state or country other than your state of legal residence? If so, please enter:

State/country of school attendance 

4. Do you live outside of the 50 United States, District of Columbia, or Puerto Rico? Yes No 

If so, how long have you lived in this location? 

 If your state of legal residence and permanent address differ, or you answered yes to either 3 or 4, call 319/688-4345 or 

email PSP@act.org before continuing. This may affect your status as a candidate for the program. 

5. Telephone (_____) ______-__________ Foreign phone 

6. DOB _____/_____/_____ Age 

7. SSN _______-_______-________

8. Contact information where you can be reached until June 20, if different from those provided above:

Mailing address 1 

Mailing address 2 

City State ZIP Code 

Province Country Foreign ZIP 

Telephone (_____) ______-__________ Foreign phone 

9. E-mail 

10. High school 

High school address 1 

High school address 2 

City State ZIP Code 

11. On the line below, print 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. 

First MI Last Suffix 

12. On the line below, print your name as you would want it to appear on a Presidential Scholar medallion. This information 

cannot be revised at a later date.

First MI Last Suffix 

13. 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.

Teacher name Title First MI Last Suffix 

Teacher school 

Teacher school address 1 

Teacher school address 2 

City State ZIP Code 

Teacher’s primary subject area 

Teacher home address 1 

Teacher home address 2 

City State ZIP Code 

Province Country Foreign ZIP 

OMB No. 1860-0504 – Approved for use through 7/31/15
SUPPORTING INFORMATION FOR THE 2015 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, (Full name) , 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 with the Program. I am (check one) willing unwilling to 

appear on radio and/or television if such arrangements can be made by the U.S. Department of Education in connection 

with the Presidential Scholars Program.

Student’s signature Date 

Parent’s or legal guardian’s signature Date 

CANDIDATE’S BIOGRAPHICAL QUESTIONNAIRE 

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

Sex: Male Female

Legal name in full (Print/Type) Last First MI 

Permanent home address Street City ST

Telephone (_____) ______-__________ DOB _____/_____/_____ Age 

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. 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. 20202-8173. 

OMB No. 1860-0504

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B. Education

1. Name of high school currently attending 

City State/Country ZIP Code 

SAT: Verbal/Critical Reading Math Writing Test Date 

ACT: English Math Reading Science Writing Composite Test Date

2. List any other schools that you attended in the last four years in order of attendance, with the most recent one first.

Name of school Location (city and state) Dates of attendance

1.

2.

3. List any advanced or special program, courses, or summer courses you have taken that would not be listed on your transcript. 

List the most recent first. Do not list AP or honors courses here; they will appear on your transcript.

Course or program Name of school Location (city and state) Dates of attendance Hours per week

1.

2.

4. Name of first-choice college or university 

City State 

5. What course of study (major) would you like to pursue in college? (You may indicate more than one or answer 

“undecided.”) 

6. Do you plan to go to graduate or professional school? 

7. Have you made any career decisions? Yes No 

If yes, specify: 

C. Activities and Work Experiences

1. List activities in which you have participated in your school (such as academics, publications, debating, dramatics, sports, 

music, art, student government, and clubs). Place an “X” in front of those activities you consider most important. Dates must be 

in the format MM/DD/YYYY. Estimate dates as best you can.

Activity

Dates of 

participation

Hours per 

week Offices held Special awards or honors

1.

2.

3.

4.

5.

6.

7.

8.

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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.

Talent or activity Periods of participation Special honors, recognition, or awards

1.

2.

3.

4.

5.

6.

7.

8.

3. List community activities in which you have participated without pay (such as hospital volunteer, religious work, 

drug/teen/homework hotlines, or outreach programs).

Type of work Name of agency or organization Dates of participation

Hours per 

week Special awards

1.

2.

3.

4.

5.

6.

7.

8.

4. List jobs you have held in the past three or four years. Use separate lines for summer and school year employment.

Job and type of work Employer

SummerSchool 

year

Approximate dates 

of employment

Approximate number of 

hours per week

1.

2.

3.

4.

5.

6.

7.

8.

OMB No. 1860-0504

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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.

D. Candidate’s Self Assessment

1. Describe any characteristics of your family or your community that have been important to your personal development.

2. 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.

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Name (Print/Type) 

3. 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?

4. 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?

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E. Name the teacher or instructor who has influenced you most significantly during your school years and whom you would like 

honored. Please be sure to print or type the teacher’s name clearly.)

Teacher name Title First MI Last 

Teacher’s school:

Name 

City ST ZIP Code 

Teacher’s primary subject area 

Explain the reason for your selection.

Please proofread your responses and review this form to make sure you have answered all questions completely. By signing 

this document you are certifying that all information contained in your application is accurate and correct, and that you 

have read the “Important Submission Requirements” document posted on the U.S. Presidential Scholars Program website 

with the downloadable application materials. 

Date Signature 

This form must be returned to:

U.S. Presidential Scholars Program

327 2nd St., Suite 103

Coralville, IA 52241

and RECEIVED no later than February 26, 2015

OMB No. 1860-0504

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CANDIDATE ESSAY

Name State 

Topic: Please attach a photograph of something that or someone who has great significance to you. Explain that significance. Note: 

If you are visually impaired, you are not required to attach a photograph. Please write about something that or someone who has great 

significance to you.

Your essay should demonstrate style, depth and breadth of your knowledge, and individuality. Confine your response to the front side 

of this page. The photograph must be stapled to this page and must not be larger than 5” x 7”. Photographs will not be 

returned. Typewritten essays are preferable. Font size must be 11 points or larger. If not typed, please print, using black or blue 

ink.

OMB No. 1860-0504

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PRESIDENTIAL SCHOLARS PROGRAM

VOLUNTARY SURVEY FORM

The following information is requested on a voluntary basis. The information will be used for statistical 

purposes only and will remain confidential.

Please check one:

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture 

or origin, regardless of race.

Not Hispanic or Latino

Check the box next to the race(s) with which you most closely identify. You may choose all that 

apply.

American Indian or Alaska Native

A person having origins in any of the original peoples of North and South America (including 

Central America), and who maintains tribal affiliation or community attachment.

Asian

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the 

Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, 

Pakistan, the Philippine Islands, Thailand, and Vietnam. 

Black or African American

A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific 

Islands.

White 

A person having origins in any of the original peoples of Europe, the Middle East, or North 

Africa.

Do you consider yourself to be physically challenged or disabled? Yes No 

If so, please briefly describe your disability: 

OMB No. 1860-0504

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2015 PRESIDENTIAL SCHOLARS PROGRAM 

SECONDARY SCHOOL REPORT

Legal name of student Last First MI 

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.

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.

Student’s signature Date 

Parent’s or legal guardian’s signature Date 

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.

School Name City ST ZIP Code Phone 

Important Instructions for Evaluator and Principal:

1. 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.

2. 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.

If you submit a letter of recommendation, your student’s application will be reviewed as it stands without the 

letter of recommendation, placing your student at a disadvantage. If you wish, you may cut/copy and paste 

your answers to the questions on this form from a letter of recommendation.

3. In order to process this student’s application, we must receive

 this completed form;

 a 7-semester secondary school transcript, including grades 9-12 (must be sent in hard copy),

 SAT/ACT scores and any AP test scores (copies are accepted; need not be official); and

 a school profile, if available.

4. 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. Return the signed envelope to the student for submission with his or her 

application materials, in time to meet the RECEIPT deadline noted below. If you need assistance with this 

requirement, call 319/688-4345, 8:30 am – 5:00 pm Central Time.

All application materials, including this form and transcripts, must be received by 5:00 P.M. Central Time, 

February 26, 2015. Any application materials not received by that deadline will render the student’s 

application ineligible for review, regardless of who sends them.

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* Items A-F are required and must be completed by a school official (Counselor, Principal, etc.).

A. Name of principal Last First MI 

B. Are you confident that the student will receive a school diploma during the current academic year?

Yes No If no, please explain. 

C. Expected date of graduation Month / Year

D. Student’s class rank Number of students in class School does not rank students. 

E. Student’s grade point average on a point scale, based on semesters.

F. Number of AP courses your school offers: Number this student will have taken by graduation: 

AP exams taken and results: 

G. Who is evaluating the student on the following pages?

Name Relationship to student (e.g., Teacher/Counselor)

Length of relationship If teacher, please state subject(s)

In items H-O, please be concise. Use examples to support your comments. Limit your response to the space provided.

H. 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?)

I. Considering this student’s interests, work habits, and life goals, what is your assessment of the chances that the student will be 

motivated to take advantage of the opportunities available in college? Please give reasons for your assessment.

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J. Does your school have a service requirement? Yes No If yes, number of hours and type of service required:

This student has exceeded met not met the service requirement.

What special features are part of your school’s curriculum (e.g. AP and honors courses, college study, independent study)? Has 

the student taken advantage of the most challenging opportunities your school has to offer? 

K. Has this student given any strong evidence of leadership ability? Yes No

Please explain the criteria on which you base your judgment and how the student meets those criteria. Include a discussion of 

the student’s principal strength.

L. Describe how this student demonstrates strong character (e.g. integrity, independence, loyalty, patriotism, self-discipline,

employment responsibilities, willingness to work hard, kindness, commitment to high ideals, and caring for others).

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M. 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.

N. 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?

O. What areas, academic or otherwise, have most challenged this student?

Date Evaluator’s Signature Title 

Date Principal’s Signature Title 

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 return the envelope to the student 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 319/688-4345, 8:30 am – 5:00 pm Central Time.

OMB 1860-0504

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