Department of Defense National Defense Scrience and Engineering Graduate (NDSEG) Fellowships Program

0701-XXXX
Expires:
XX-XX-XXXX

Application for Fellowship
Agency Disclosure Notice
The public reporting burden for this collection of information, 0701-0154, is estimated to average 12 hours 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 the burden estimate or burden reduction suggestions to the Department of Defense, Washington
Headquarters Services, at whs.mc-alex.esd.mbx.dd-dod-information-collections@mail.mil. Respondents should be aware that notwithstanding
any other provision 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.
Privacy Act Statement
National Defense Science and Englneer1ng Graduate (NOSEG) Fellowships are awarded under the authority or section 2191 of Tittle 10, United
States Code. Information requested on application form, and fellows' progress reports is solicited under this authority. The application
information may be disclosed to reviewers and assistants as part of the NOSEG process for evaluation and selection of qualified applicants.
Information provided in applications and fellows' progress reports may be disclosed to academic institutions attended by applicants and fellows
to provide or obtain data regarding the applicant review process, award decisions, or the administration of awards. Aggregated data based on
application materials may used in management reports designed to evaluate the direction and progress or the program as a whole and for
reporting within the Deportment or Defense (DoD) and Federal Government. Attribution of specific data to individual applicants will be avoided,
whenever possible, in using information provided. A fellow's application information may be shared with DoD laboratory personnel, for the
purposes of receiving Information about summer employment or other opportunities, only If an applicant consents to sharing of the application
information using the cheek box within the application. A list or fellowship winners may be published.
Submission of the Information requested on the application is voluntary. Omission of any particular Item not necessary to establish eligibility
will not preclude the application review, although failure to provide full and complete information needed to evaluate all or the merits of the
application may reduce the possibility of receiving an award. In order to determine the degree to which members or diverse sections or the
eligible population are aware of and apply for this program, completion or the demographic fields on the application relating to gender, ethnicity,
and race, Is requested, but voluntary; omission or any demographic field information will not affect award consideration. Applicants will be
considered for award of fellowships based on merit and without regard to race, color, religion, national origin, gender, or age.

Application for Fellowship

Please complete all required fields (Note: The pre-doctoral fields are designed to capture education information for
traditional applicants who have completed their Master’s degree and will attend a different university for the PhD). If you
will be attending the same institution, you may re-enter the graduate information in this section).
To trigger the reference link, click the "next" button. On the following page it will ask you to 'submit" your application. Upon
submission you will receive an email with the reference link to forward to your recommenders (This happens the first time
logging in ONLY). After submission, complete the EEO Information. If you do not receive the reference link, there is a
reference form you can download from the NDSEG website. Please note, submitting your application does not mean it is
FINAL. Applicants can log back in and update information.
You may login to the application to complete/update your information continuously until the application period closes. Just
remember to click the save button to save your information. To log back into your application, return to the application
portal on the website and login as a returning user.

CONTACT INFORMATION
Last Name
First Name
Middle Initial
CURRENT ADDRESS:
Address
Suite/Apt.
Country

United States

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City
State

VA

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Zip
Home Phone

(

)

-

Cell Phone
Email Address
Work/School Email Address
Date Address is Effective

(Select Month)

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(Day)

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(Year)

PERMANENT ADDRESS
Street Address
Permanent Address Suite/Apt #

Permanent City
Permanent State

AL

Permanent Country

United States

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CITIZENSHIP
US Citizen

 Yes

No

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If "NO", Country of Citizenship
Dual Citizenship?

Yes

No

Dual Country Name
EDUCATION
UNDERGRADUATE EDUCATION
Please list your undergraduate information
Undergraduate School Name
Undergraduate Country

United States

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Undergraduate City
Undergraduate School State

AL

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Undergraduate School Zipcode
Please list the start date of attendance at
this institution
Please list the end date of attendance at
this institution
Please list your Major in Undergraduate
School
Please list your undergraduate minor
Please list your undergraduate second
minor
Please list your overall GPA
Please list your major GPA
Please list the type of degree received
(BA, BS, etc.).
Please list your first and last name when
attending this institution (if different from
your current name)
GRADUATE EDUCATION
Please list your graduate school Information in this section
Graduate school name
Graduate School Country

United States

Graduate School City
Graduate School State
Graduate School zipcode
Graduate School Start Date (this can be
estimated)
Graduate School end date
Graduate School Major
Graduate School specialization
Graduate School GPA

AL

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Graduate Record Examination (GRE)
Scores-General Test Only
Graduate School Degree Type (MA, MS,
etc.)
Name when attending Graduate School (if
Applicable)
PREDOCTORAL INSITUTION (If different from Graduate School)
Please enter your Pre-doctoral Institution Information
Pre-doctoral Institution Name
Pre-doctoral Country

United States

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Pre-doctoral Institution City
Pre-doctoral Institution State

AL

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Pre-doctoral Institution Zipcode
Pre-doctoral Major
Pre-doctoral Degree Type
Pursuing/received (PhD, MD, DPH, etc.)
Pre-doctoral GPA
Please list you name when attending the
Pre-Doctoral Institution
Please list any additional education here.
ADD EDUCATION
School:

School Type:

Degree Type:

Major:

Begin Date:

End Date:

(Please Select a Value)

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GPA:
0
School:

School Type:
(Please Select a Value)

Degree Type:

Major:

Begin Date:

End Date:

GPA:
0
ADVISOR INFORMATION
If known, please list your Advisor Information
Advisor First Name
Advisor Last Name
Advisor Email Address

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Advisor Telephone Number
WORK HISTORY
Work Experience
ADD WORK HISTORY
Company Name:

Begin Date:

End Date:

City:

State:
(Please Select a State)

Postal Code:


Job Title:

Supervisor Name:

Supervisor Email:

Supervisor Phone:

Rate Of Pay Start:

Rate Of Pay End:

$0.00

$0.00

Duties:

Reason For Leaving:

Company Name:

Begin Date:

End Date:

City:

State:
(Please Select a State)

Postal Code:


Job Title:

Supervisor Name:

Supervisor Email:

Supervisor Phone:

Rate Of Pay Start:

Rate Of Pay End:

$0.00

$0.00

Reason For Leaving:

Company Name:

Begin Date:

End Date:

City:

State:

Postal Code:

Duties:

(Please Select a State)



Job Title:

Supervisor Name:

Supervisor Email:

Supervisor Phone:

Rate Of Pay Start:

Rate Of Pay End:

$0.00

$0.00

Duties:

Reason For Leaving:

Licenses and Certificates
ADD LICENSING
License Name:

License Agency:

License Number:

State Issued:

Begin Date:

Expiration Date:

(Please Select a State)

Foreign Language
Computer / Software Skills

Military Experience
ADD MILITARY
Branch:

Service ID:

Location:

Start Rank:

Discharge Rank:

Current Rank:

Begin Date:

End Date:

Address:

City:

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Comments:

State:

Postal Code:

(Please Select a State)

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Country:

Honors:

United States of America

Expertise:

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Comments:

SOCIAL MEDIA
LinkedIn
Facebook
Twitter
References
ADD REFERENCE
First Name:

Last Name:

Phone:

Email:

Relationship:

Years Known:
0

First Name:

Last Name:
;asldkfja

Phone:

Email:

Relationship:

Years Known:
0

First Name:

Last Name:

Phone:

Email:

Relationship:

Years Known:
0

PERSONAL STATEMENT
Personal Statement Upload: Should
Click Here To Upload File
include the following. What are your short
and long-term professional goals? How
did these goals develop? How have you
already begun to lay the foundation for
these goals? How does this fellowship fit
into these goals?
ADDITIONAL REQUIREMENTS

Disciplinary Action:

Essay/Proposal: Please provide the Title
of your proposed research that would be
relevant to the Department of Defense
(DoD) - Please submit a proposal relevant
to the DoD Agency (ONR,ARMY,
AIRFORCE)/field that interest you. The
reader should be convinced that your
project will make an important
contribution to the Agency and be a
persuasive argument for why your
project/proposed training deserves to be
funded.
Essay/Proposed Research Upload

Click Here To Upload File

Resume Upload

Click Here To Upload File

Transcript Upload

Click Here To Upload File

GRE Scores Upload

Click Here To Upload File

Additional Upload 3

Click Here To Upload File

Applicant's Statement
I certify that the facts contained in this application are true and complete. I understand that, if selected for a fellowship,
falsified statements on this application shall be grounds for immediate cancellation of the fellowship. I authorize
investigation of all statements contained in this application as may be necessary in arriving at a fellowship decision. I
authorize my employers, and references to give any and all information they may have concerning my previous employment
and any pertinent information they may have otherwise to Solutions Through Innovative Technologies, Inc. (STI-TEC) and I
release all parties from all liability for any damage that may result from furnishing same.

Disclosure and Release
In connection with my application for the National Defense Science and Engineering Graduate Fellowship (NDSEG) program,
I understand that consumer reports, including investigative consumer reports, which may contain public record information,
may be obtained as part of the pre-fellowship background investigation, or at any time during my fellowship. These reports
may include, the following information; academics, performance evaluation, employment history, attendance, character,
credit history, names and dates of previous employers, reason for termination of employment, work experience, accidents,
etc. I further understand that such reports may contain public record information concerning my driving records, worker's
compensation claims, bankruptcy proceeding, criminal records, etc., from federal, state and other agencies. I hereby release
any person, agency, organization, or institution, including National Defense Science and Engineering Graduate Fellowship
(NDSEG), Department of Defense ( DoD) and Solutions Through Innovative Technologies, Inc. (STI-TEC), (STI-TEC), from any
and all liability whatsoever resulting from this inquiry. This release is binding, now and in the future, on my heirs, assigns,
associates, and personal representative(s) of any nature.
APPLICANT'S STATEMENT

I AGREE TO THE ABOVE STATEMENT

I AGREE

I AGREE TO THE ABOVE DISCLOSURE AND RELEASE

APPLICANT NAME:
DATE:

(Select Month)

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(Day)

SAVE

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(Year)

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