West Houston Center for Science and Engineering Application Form for Materials Science Scholarships

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1 West Houston Center for Science and Engineering Application Form for Materials Science Scholarships Please enter electronically (PDF), include any attachments and to Please read this application thoroughly and address all questions, requests for information, and provide additional written responses and short essays as required. All parts of this application must be complete in order to be considered for admittance into the West Houston Center Materials Academic and/or Research Scholarship/Stipend. Citizenship Requirements for WHC Scholarships: Open to US Citizens, Permanent Residents and Foreign Students (must provide copy of passport and visa) Personal Information Date of Application (month/date/year): Name: First: Middle Initial: Last: HCC ID #: Gender: Male Female Date of Birth (MM/DD/YYYY): Mailing Address: (Program Correspondence and Award notification will be sent to this address) Number & Street: Apt No.: City: State: Zip Code Phone: (###) ###-#### Home Phone: Cell Phone: 1

2 E mail: Permanent Address (if different from above): Number & Street: Apt No.: City: State: Zip Code Please check the appropriate box: U.S. Citizen Permanent Resident Foreign Student Please denote which scholarships and/or Program are you applying for: Fall 2015 WHC Academic Scholarship for Materials Science Fall 2015 WHC Research Scholarship/Stipend for Materials Science Study Due Dates For Both: August 15, 2015 Financial Information Have you applied for Financial Aid (FAFSA) for the upcoming academic year? Yes No Please describe any circumstances regarding your need for financial assistance that warrant consideration and award of these funds or entry into WHC programs. Ethnic Classification: White, Non- Hispanic African-American Hispanic Asian Hawaiian/Pacific Islander Alaskan/American Indian Other Family Education: Please state the highest level of education received by your: Mother: High school diploma Some college College degree Post graduate Father: High school diploma Some college College degree Post graduate Applicant Academic and Educational Information 2

3 School Currently Attending/Last Attended: The above listed educational institution is a: High School Two-Year College Four-Year College Graduate School Please list all high schools and colleges attended: School Dates Attended Degree GPA What is your intended major/field of study/specialization? How many semester hours to you intend to carry while receiving this scholarship? What is your anticipated completion and/or transfer date from this college? Do you plan on transferring to a University? Yes No If yes, which University? Information About You (Please attach a separate sheet is necessary) Please List all Awards, Prizes, Honors and Scholarships that you have received: Please List Extracurricular Activities, Club Memberships and Leadership Positions (High School through College) 3

4 Please provide a summary of your work experience (Please attach a resume if appropriate) Name of Employer Position/Duties Dates of Employment Please provide a personal statement stating: Your academic and career goals, Why you applying for this scholarship/research stipend, What is the benefit that you will derive from acceptance into the WHC Materials Science Scholarship program? Please attach an additional page(s) if necessary, please submit a PDF document) Note: For the West Houston Center Materials Science Scholarship and/or the West Houston Center Research Scholarship you must be a declared science, engineering or math major, enrolled as a full time HCC student. Foreign students may apply for this scholarship/research scholarship. Certification and Release I, THE UNDERSIGNED, HEREBY CERTIFY THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AUTHOIRIZE HOUSTON COMMUNITY COLLEGE TO RELEASE THE INFORMATION CONTAINED WITHIN THIS APPLICATION (INLCUDING ACADEMIC RECORDS AND PERSONAL BIOGRAPHICAL INFORMATION) TO MEMBERS OF THE SELETION COMMITTEE AND AGENCIES/DONORS PROVIDING FUNDS FOR THE SCHOLARSHIP AND THE REEMS PROGRAM. I UNDERSTAND THAT THE NAMES OF THE SCHOLARSHIP AWARDS RECIPIENTS AND NAMES OF THE REEMS SCHOLARS MAY BE PUBLISHED IN AREA NEWSPAPERS AND RECIPIENTS MAY BE ASEKD TO PROVIDE A PHOTOGRAPH. NON COMPLIANCE WITH ELIGIBILITY REQUIREMENTS OF THE SCHOLARSHIP AND/OR THE REEMS PROGRAM MAY RESULT IN MY REIMBURSEMENT OF MONIES TO THE RESPECTIVE SCHOLARSHIP AND/OR PROGRAM FUNDING AGENCY. ANY DEBTS OWED TO HOUSTON COMMUNITY COLLEGE MUST BE PAID PRIOR TO THE DISBURSEMENT OF SCHOLARSHIP MONIES OR ENTRY INTO THE REEMS PROGRAM. ABOVE STATED AND ATTACHED 4

5 INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I AUTHORIZE HCC TO REQUEST, RECEIVE, AND RELEASE INFORMATION CONCERNING MY ACADEMIC AND FINANCIAL STATUS TO/FROM THE HCC REGISTRAR. STUDENT S SIGNATURE: DATE: APPLICATION CHECKLIST COMPLETED APPLICATION FORM: Please do not forget to sign OR electronically sign the application NEXT PAGE UNOFFICIAL TRANSCRIPT: Most recent college or high school academic transcript showing all enrolled, completed, and transferred college credits. This transcript must include your most recent grades. ADDITIONAL DOCUMENTATION: Attach additional documentation as needed to comply with the various requests for personal and work related information. NOMINATION FORMS: From your current academic advisor, teacher, or professor who can discuss your leadership, academic and personal achievement, as well as your potential for future success. Please mail, fax or hand deliver the complete application package to the following address by 5 PM of the due date, ATTN: Bartlett M. Sheinberg Center Director West Houston Center for Science and Engineering 2811 Hayes Road Suite A.408 MC 1524 H Houston, TX Fax: Phone: Mobile Phone: If there are any questions please, contact the West Houston Director at or (713) FOR INTERNAL USE ONLY: DATE COMPLETED STUDENT APPLICATION RECEIVED: DATE RECOMMENDATION LETTER 1 RECEIVED DATE RECOMMENDATION LETTER 2 RECEIVED 5

6 DATE RECOMMENDAITON LETTER 3 RECEIVED Bartlett M. Sheinberg Center Director West Houston Center for Science & Engineering 2811 Hayes Road MC 1524H Houston, TX T:

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