## 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 th e 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 inf

ormation 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.

F irst 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

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## SUPPORTING INFORMATION FOR THE 201 5 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. Furnis hing 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 CANDIDA CY

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 Presiden tial 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 tel evision if such arrangements can be made by the U.S. Department of Education in connection

with the Presidential Scholars Program.

Student’s s ignature Date

Parent’s or l egal g uardian’s s ignature 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 a ttach additional pages.

A. Biographical Information

Sex: M ale 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 commen ts 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

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Approved for use thro ugh 7/31/15B. 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 course s you have taken th at 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 pe r 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 profess ional 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, debati ng, 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 pe r

week Offices held Special awards or honors

1.

2.

3.

4.

5.

6.

7.

8.

OMB No. 1860

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Approved for use through 7/31/15Name (Print/Type)

2. List any special talents (in areas such as music, the arts, sports, published w riting 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 hospi tal 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 Sum

mer School

year Approximate dates

of employment Approximate number of

hours per week

1.

2.

3.

4.

5.

6.

7.

8.

OMB No. 1860

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Approved for use through 7/31/15Note: 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 siz e 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.

OMB No. 1860

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Approved for use through 7 /31/1 5Name (Print/Type)

3. What is the most significant contr ibution 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 mis take you made or a challenge you faced. How did you respond to that mistake or challenge, and what did

you learn from your experience?

OMB No. 1860

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Approved for use through 7/31/15E. Name the teacher or instructor who has influenced you most signific antly during your school years and w hom you would like

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

Teacher name Title First MI Last

T eacher’s school :

Name

City ST ZIP Code

Teacher’s primary subject are a

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 ac curate and correct, and that you

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

wi th the downloadable application materials.

Date Signature



### This form must be returned to:

U.S. Presidenti al Scholars Program

327 2 nd 

### St., Suite 103

Coralville, IA 52241

and RECEIVED no later than February 2 6

, 201 5

OMB No. 1860

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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 photo graph. 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 fr ont 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

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Approved fo r use through 7/31/15

# 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 i dentify. 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 at tachment.

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 Island s, 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 peo ples 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

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# 201 5 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 second ary 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 y ears, 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 hon or 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 blu e 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 let ter 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 ac ross 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 stu dent’s

application ineligible for review, regardless of who sends them.

OMB No. 1860

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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 Numb er of students in class School does not rank students.

E. Student’s grade point average o n 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 wi ll be

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

OMB No. 1860

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Approved for use through 7/31/15J. Does your scho ol 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 opport unities 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 hi gh ideals, and caring for others).

OMB No. 1860

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Approved for use through 7/31/15M. 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 th e student’s application or transcript

– additional qualities, anecdotes, circumstances, or backgrou nd 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, atta ch 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

Approved for use through 7/31/15