SMART Scholarship Recruitment Internship Request

SMART Scholarship-for-Service Program

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OMB No.

Recruitment Internship Request

OMB Approval expires

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 2192a, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 5 U.S.C. 3304, Competitive service
examinations; 20 U.S.C. 17, National Defense Education Program; and E.O. 9397 (SSN), as amended.
PRINCIPLE PURPOSE(S): To record a SMART Participant’s internship experience within 14 days of the conclusion of the internship.
ROUTINE USES: Disclosure of records are generally permitted under 5 U.S.C. 552a(b) of the Privacy Act of 1974, as amended. To academic institutions for the
purpose of providing progress reports for applicants and participants; to consumer reporting agencies as defined in the Fair Credit Reporting Act (15 U.S.C.
1681a(f)) or the Federal Claims Collection Act of 1966 (31 U.S.C. 3701(a)(3)). The purpose of this disclosure is to aid in the collection of outstanding debts owed to the
Federal government, typically to provide an incentive for debtors to repay delinquent Federal government debts by making these debts part of their credit records;
Applicable Blanket Routine Use(s) are: Law Enforcement Routine Use, Congressional Inquiries Disclosure Routine Use, Disclosure When Requesting Information
Routine Use, Disclosure of Requested Information Routine Use, Disclosure to the Department of Justice for Litigation Routine Use, Disclosure of Information to the
National Archives and Records Administration Routine Use, and Data Breach Remediation Purposes Routine Use.
The DoD Blanket Routine Uses set forth at the beginning of the Office of the Secretary of Defense (OSD) compilation of systems of records notices
may apply to this system. The complete list of DoD Blanket Routine Uses can be found Online at:
http://dpcld.defense.gov/Privacy/SORNsIndex/BlanketRoutineUses.aspx
The applicable Privacy Act System of Records Notice is DUSDA 14, Science, Mathematics, and Research for Transformation (SMART) Information Management
System, found at http://dpcld.defense.gov/Privacy/SORNsIndex/DODwideSORNArticleView/tabid/6797/Article/570592/dusda-14.aspx
DISCLOSURE: Voluntary; however, failure to provide the requested information could result in SMART participant not being compliant with SMART policy.
INSTRUCTION: All multi-year participants complete internships with their sponsoring facility (SF) each year the award crosses a summer period. Internships are between 8 and 12 weeks
unless the SF requests a different length. Participants work with their SF to coordinate internship start and end dates that are agreeable to the SF. Additional information can be found in
the Participant Handbook.

SECTION 1 – Participant Information
Name (LAST, First, MI):
Phone:
Degree Level Funded by SMART:
BS
BS/MS
Degree Completion Date:

Cohort Year:
Email:
MS

PhD

Field of Study:
Degree Conferral Date:

SECTION 2 – Internship Information
Sponsoring Facility:
First Day at Sponsoring Facility:
Last Day at Sponsoring Facility:
Facility POC Name:
Facility POC Phone:
Facility POC Email:
Do You Anticipate Internship-Related Travel Within Your Internship Period?*
Yes
No
If yes, please list the dates and destinations.
Note: * – Travel during the internship is the financial responsibility of the SF.

SECTION 3 – Location Information
Academic Address Line 1:
Academic Address Line 2:
City/State:
Sponsoring Facility:
Sponsoring Facility Address Line 1:
Sponsoring Facility Address Line 2:
City/State:
SECTION 4 – Academic Information
Are you currently on Academic Probation?
Do you anticipate that your cumulative GPA will be below 3.0?
SECTION 5 – Security Clearance Information
Security Manager Office (SMO) Code**:

Zip Code:

Zip Code:

Yes
Yes

No
No

Security Manager Phone:

Note: ** – The Security Manager Office (SMO) code is a unique identifier for your SF in JPAS. This code is required in order to provide your SF verification of your security clearance and need for access during your
internship. To obtain your SF’s code and contact information for their security manager, please ask your mentor or facility POC. Your Internship Request is incomplete without this information.

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Recruitment Internship Request, revised 10/09/2015

SMART Scholarship-for-Service Program

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SECTION 6 – Statement of Understanding
By signing below I certify that all information provided is true and accurate to the best of my knowledge.
Please initial:
____ I have attached an email from my mentor/supervisor/facility POC confirming the dates of my internship.
____ I understand that if my cumulative GPA falls below 3.0 after this request is processed, but before I travel, I must notify
The SMART Program immediately.
____ I understand that if I receive Internship Support Payments and then do not perform my internship, I may be responsible for repaying all
Internship Support Payments expended on my behalf.
Participant Signature:

Date:

--------------------------------------------------DO NOT WRITE BELOW THIS DOTTED LINE / SMART SCHOLARSHIP PROGAM USE ONLY-----------------------------------------------------SECTION 7 – CA Additional Information/Remarks

SECTION 8 – SMART Program Review
Verified clearance status
Cleared
Not cleared
CA action needed _____________________________________________
Verified academic standing
GPA above 3.0
GPA below 3.0
CA action needed _____________________________________________
Verified distance between academic address and SF
Eligible for ISP
Not eligible for ISP
Verified cohort specific ISP Amount $____________ per week
Number of Weeks:

Total Amount of ISP funding:

Payment Date:
Internship Report Due Date:
Cohort Administrator Name:

Cohort Administrator Signature:

Date:

Agency Disclosure Notice
The public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington
headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East Tower, Suite 02G09, Alexandria, VA 22350-3100 OMB Control
Number: 0704-0466. Respondents should be aware that notwithstanding any other provisions of law, no person shall be subject to any penalty for failing to comply
with a collection of information if it does not display a currently valid OMB control number.
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Recruitment Internship Request, revised 10/09/2015