APPLICATION SUBMISSION INSTRUCTIONS Please use this as a checklist to help ensure that your application is complete

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1 APPLICATION SUBMISSION INSTRUCTIONS Please use this as a checklist to help ensure that your application is complete All pages of the application and support materials should be submitted on 8½ x 11 or A4 sized paper. The application and all attachments must be typewritten and in English. All pages must be single sided; information on the back of a page is not transmitted to the review committee. Two sided submissions render the application ineligible for review. Please remove all staples. Your application will be scanned. You may use paper clips (preferably one large clip) to hold your application together. The application should be submitted flat in a 9 x 12 or larger envelope. Please put the pages in this order: Application, with numbered pages in order. Every page of the application must be completed and included, and the application must be signed. For applicants who use hearing aids, an unaided Audiogram performed within the past 24 months (this should be one page, not the entire narrative report). A visit report or narrative will not suffice. For applicants with cochlear implants, a CI programming report performed within the past 24 months. Official transcripts for high school and/or college are required for all applicants. High school seniors submit transcripts for grades 9 11 and the first semester of grade 12. A cumulative non weighted GPA must be provided by the school. If a cumulative weighted GPA is indicated on the transcript, a cumulative non weighted GPA must also be provided, either on the transcript or by a school official on school letterhead, on a 4.0 or 5.0 or percentage scale. VERY IMPORTANT: If a cumulative non weighted GPA or percentage equivalent is not provided on the transcript or in a separate letter from the school, the application will be considered incomplete. This applies to all students regardless of country. No exceptions will be made. College freshman need transcripts for grades 9 12 (cumulative non weighted GPA requirement listed above applies for high school transcripts) and the first semester of college. College sophomores or higher need college transcripts for all college semesters completed (high school transcripts are not needed). If your school will release transcripts only directly to us, transcripts should be sent to the delivery address above. Transcripts must be received by the deadline or your application will be considered incomplete. Verification of the applicant s application, acceptance or enrollment in a mainstream and accredited university/college; a readable photo copy of an acceptance letter, confirmation of online application or transcripts from the college of choice are acceptable. Graduate students will need the university to confirm full time graduate status. Applicant Essay, as indicated in the application (typed and a maximum of one single sided page). A personal essay longer than one page will result in an ineligible application. No Exceptions. Three letters of recommendation from three different individuals. Letters must be no longer than two singlesided pages. At least one letter must be from one of the applicant s teachers or professors in an academic or studio subject (e.g., history, chemistry, theatre or dance). All three letters may be from teachers or professors or two letters may be from other individuals such as a coach, extracurricular activity sponsor, hearing health professional (for example, a teacher of the deaf, hearing services instructor, speech language pathologist, audiologist), employer, etc. College freshmen should include at least one letter from a college professor, college sophomores or higher should include at least two letters from college professors and none from high school teachers. In addition to the letter, each recommender MUST provide a completed cover sheet; letters without a cover sheet will render the entire application incomplete. If the letter is provided to you in a sealed envelope, you may leave it that way; if the letter is not provided to you in a sealed envelope, please remove any staples and attach it flat to the application. Letters of recommendation received separately from the application will not be considered. No Exceptions. Block out your social security number, tax payer ID number or Personal Health Information (PHI) where they appear. Please do NOT include any information that has not been requested; extra items will not be considered.

2 COLLEGE SCHOLARSHIP APPLICATION 2016 Responses in the application as well as the essay must be typewritten. I would like to be considered for the STEM summer internship opportunity. Your complete application must be received by AG Bell no later than 5:00pm EST on January 22, IDENTIFYING INFORMATION Applicant Name (First, MI, Last): Date of Birth (MM/DD/YY Y) Gender: Male Female Complete Mailing Address: Address: Communication throughout the process is conducted only via . Is applicant or applicant s parent a current AG Bell member? Yes No Note: AG Bell membership may be required for some scholarships HEARING HEALTH & COMMUNICATION INFORMATION Is your hearing loss bilateral? Yes No Age when hearing loss was diagnosed: Pure Tone Average*: *This must be completed for your application to be considered. If you have a cochlear implant, indicate CI. If you do not have a cochlear implant and your PTA is less than 60 db in your better hearing hear, you do not qualify and should not apply. If applicable, age at which applicant was fitted with hearing aid(s): If applicable, age at which applicant received cochlear implant(s) Applicant uses Listening and Spoken Language as the primary mode of communication: Yes No What other method(s) of communication and educational support service(s) are used in daily communications and educational settings? Check all that apply. S peech Reading I use sign language with: Teachers/professors Other (please describe): Cued Speech Note taker Oral Interpreter(s) Communication Access Real time Translation (CART) Auditory Listening Device, such as FM System or FM SoundField Sign Language Interpreter(s) Other (please describe): All materials MUST ARRIVE together in one package before 5 p.m. EST on March 11, Transcripts are the only supporting documentation that will be accepted separately from the application and must be received before the deadline. 1

3 ACADEMIC ACHIEVEMENTS Applicant s Current Educational Status: High School Senior College Freshman College Sophomore College Junior College Senior/Rising Graduate Student Rising Graduate Student Graduate Student, first year Graduate Student, second year Rising Doctoral Student Doctoral Student, first year Doctoral Student, second year Current high school seniors need to complete this: High school non weighted cumulative GPA*: on a scale of: *Must be at least 3.25 on a non weighted 4.0 scale (or scale equivalent) to be eligible; non weighted cumulative GPA must be officially provided by the school, if not on the transcript, then in a separate letter. Official transcripts are a required element. Non U.S. Applicants, please indicate your non weighted GPA equivalent based on your country s educational system: Cumulative GPA, equivalent or percentage grade must be provided on transcript or in a letter from a school official. Current or returning college students need to complete this: College cumulative GPA*: on a scale of: *Must be at least 3.25 on a 4.0 scale (or equivalent) to be eligible. Official transcripts are a required element. Non U.S. Applicants: please indicate your GPA equivalent based on your country s educational system: Cumulative GPA, equivalent or percentage grade must be provided on transcript or in a letter from a school official. COLLEGE INFORMATION For the academic year, I am attending or will attend: I have applied to (list top three colleges): If accepted, I plan to attend: Note: If you have not yet heard from all of the colleges you applied to or haven t made a final decision about where you ll attend college, once you have made a decision, please inform AG Bell by sending an to This information will be forwarded to the review committee during their deliberations. Expected date of graduation/degree completion: Areas(s) of academic concentration/major(s): Career plans, in general: Please tell us, in general, how you plan to pay for college and if you have other scholarships. If you are selected to receive an AG Bell College Scholarship, please tell us how you would use the award. All materials MUST ARRIVE together in one package before 5 p.m. EST on March 11, Transcripts are the only supporting documentation that will be accepted separately from the application and must be received before the deadline. 2

4 DEMONSTRATION OF LEADERSHIP In the space below, cite one example of leadership that will introduce us to the accomplished person you are. It s helpful if you can answer questions such as: What did you do/what was your part in the project? What new information did you learn? What did you discover about yourself, about others, about the world? Where did you shine? What areas of improvement did you discover? Do not include a separate sheet of paper for this question. If you ve been featured in a published article for an achievement or demonstration of leadership that is available online, you may include the URL at the end of your narrative paragraph(s). Do NOT attach a copy of the article; it will not be forwarded to the review committee. DEALING WITH CHALLENGES In the space below, please tell us briefly about one situation that was challenging for you because of your hearing loss and how you resolved or dealt with the situation. Do not include a separate sheet of paper for this question.

5 APPLICANT ESSAY Select one of the following topics for your essay. You have successfully completed your collegiate studies and obtained your degree. Now you are interviewing for your dream job. Describe what this job is and why you should be hired. You have been elected president/leader of your country. What issues are you going to work on during your term, why have you chosen to focus on these issues, and how are you going to solve them? Describe an event or interaction that had a significant impact on you. Why was it significant? How were you impacted? What were your thoughts and reflections on this event at the time and since? How has that event or interaction changed you and/or the direction of your life? Describe what your life is like 15 years from now and the impact that you have had on those around you, personally, professionally or both. (Alternative: Write a descriptive obituary for yourself.) NOTE: Previous AG Bell Scholarship recipients may write a specific essay about your college experience. Graduate students may wish to focus on their research in their essay, which is encouraged. Your essay must be typed and is limited to one single sided page. Margins and font style/size are not dictated, as long at the essay is easily read without magnification. Handwritten essays and essays longer than one page will render the entire application ineligible. FREE FORM SHARING (optional) This is a chance to tell the committee something special about you that you haven t already shared. Do not include a separate sheet of paper. UNDERSTANDING AND AGREEMENT I certify that I use listening and spoken language as my primary mode of communication and that, to the best of my knowledge, all information contained in this application is true and accurate. I understand that if I am selected to receive an AG Bell College Scholarship Award for the academic year, AG Bell will release information stating this along with my name and city and state of residence to the media and/or the AG Bell community. I understand that the receipt of a College Scholarship is contingent upon my full time attendance at an accredited mainstream four year college or university in the coming academic year. Student/Applicant Signature (required): Parent/Guardian Signature, if applicant is under 18: Date: All materials MUST ARRIVE together in one package before 5 p.m. EST on March 11, Transcripts are the only supporting documentation that will be accepted separately from the application and must be received before the deadline. 4

6 2016 COLLEGE SCHOLARSHIP RECOMMENDATION REQUEST To the applicant: please copy this and the following page and give both to each person from whom you are requesting a letter of recommendation. To the Recommender: You are receiving this recommendation request in support of an application for an AG Bell College Scholarship for the academic year for. This is a merit based scholarship program and award selection is extremely competitive. The information you provide is a critical element of the student s application. In a one or two page single sided letter, preferably on your business or organization s letterhead, please address the following characteristics of the applicant: What is it about the applicant that makes him or her stand out from his or her peers? What are some things at which the applicant excels? What are some areas or skills which the applicant is working to improve? Describe how the applicant interacts with her or her peers, teachers, professors, etc. You may share any other information you feel would be helpful, such as the applicant s motivation, intellect, creativity, discipline and maturity. It would be most helpful if you can recall specific instances in which these qualities were revealed to you. Note: the applicant s transcripts are included in the application; we do not need to know about grades, but are interested in a descriptive narrative about growth, achievements, abilities and potential. Please Also Note: The review committee comprises individuals who work in the field of education and who are familiar with hearing loss, hearing technology and accommodations, so you do not need to describe these in detail. Letters longer than two pages will disqualify the applicant. Please do NOT staple pages together. Information must be provided on a single side of each page; the back of pages will not be transmitted to the review committee. Recommendations must be submitted by the student with the application; recommendations mailed directly to AG Bell will not be accepted. You may choose to provide your recommendation in a sealed envelope; please make sure you include both the completed cover sheet and your letter. If your position/employer precludes you from completing the cover sheet, please let the applicant know so he or she may find another reference. Cover sheets that indicate I cannot complete this or have a lot of cannot judge boxes checked will result in a poor score for the applicant, significantly reducing his or her chance for a scholarship. VERY IMPORTANT: Please return your letter of recommendation AND cover sheet to the applicant as quickly as possible so that the applicant can meet the application deadline. The cover sheet is a required element of your reference; if it is not included, the student s application will be considered incomplete.

7 AG BELL COLLEGE SCHOLARSHIP LETTER OF RECOMMENDATION COVER SHEET A cover sheet is required from each reference Name of student applicant To the individual making this recommendation: The above named student has asked you to provide a letter of recommendation for a College Scholarship. Please complete this form and include it with your letter of recommendation, and return both directly to the student applicant. This is a required element of the application. How long and in what capacity have you known the applicant? In the table below, please indicate how the applicant ranks in comparison to other students of the same year, i.e. other high school seniors, other college sophomores, other graduate students. Characteristic Top 2% Top 5% Top 10% Top 25% Top 50% Intellectual Depth Willingness to Work Hard Creativity/Imagination Emotional Maturity/Stability Motivation/Perseverance Writing Ability Skill in Oral Presentations Professional Potential Critical/Analytical Thinking Personal/Interpersonal Skills Collaborative Ability Independence/Initiative Reliability/Responsibility Work Ethic Bottom 50% Cannot Judge If you had one scholarship to award personally and the top 10 students in your school/class applied, would you award the scholarship to this student? Yes No My overall recommendation for this applicant is: Very Strong Strong Average Below Average Recommend with Reservations Name Title Organization Signature Date

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