DD 3067-8 Science, Mathematics, and Research for Transformation (S

Science, Mathematics, and Research for Transformation (SMART) Scholarship
Recruitment Internship Request

OMB NO. 0704-0466
OMB approval expires
YYYYMMDD

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 4093, Science, Mathematics, and Research for Transformation (SMART) Defense Education Program; 10 U.S.C. 133a, Under
Secretary of Defense for Research and Engineering; DoD Directive 5137.02, Under Secretary of Defense for Research and Engineering (USD(R&E)); DoD
Instruction 1025.09, Science, Mathematics, and Research for Transformation Defense Education Program.
PURPOSE: To record an internship request for a SMART Scholar.
ROUTINE USES: While the information requested on this form is primarily intended to be used internally, in certain circumstances it may be necessary to
disclose this information externally, pursuant to 5 U.S.C. 552a(b)(3), including to contractors, grantees, experts, consultants, students, and others performing or
working on a contract, service, grant, cooperative agreement, or other assignment for the Federal Government when necessary to accomplish an agency
function. A complete list of routine uses may be found in the applicable Privacy Act System of Records Notice, DUSDA 14, Science, Mathematics, and Research
for Transformation (SMART) Information Management System, found at
https://dpcld.defense.gov/Portals/49/Documents/Privacy/SORNs/OSDJS/DUSDA-14.pdf?ver=KO2ZkLWhxB3QCZoRTElMFA%3d%3d
DISCLOSURE: Voluntary; however, failure to provide the requested information may result in SMART scholar being non-compliant with SMART policy, and
subject to possible dismissal.
The public reporting burden for this collection of information is estimated to average one 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, at whs.mc-alex.esd.mbx.dd-dod-informationcollections@mail.mil. 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.
INSTRUCTION: All SMART Scholars 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. Scholars work with their SF to coordinate internship start and end dates that are agreeable to
the SF. Additional information can be found in the SMART Scholar Handbook.

SECTION 1 – Scholar Information
Name (Last, First, MI):

Cohort Year:

Phone:

Email:

Degree Level Funded by SMART:

BS

BS/MS

MS

PhD Field of Study:

NEEDS DD67

Degree Completion Date (YYYYMMDD):*

Degree Conferral Date (YYYYMMDD):**

*Degree Completion Date: Date on which an individual completes all degree requirements. This generally occurs prior to degree conferral and is not set forth on
official transcripts.
** Degree Conferral Date: Date on which a degree is bestowed upon an individual. This is set forth on the official transcript reflecting the degree earned and
may occur after degree completion.

SECTION 2 – Internship Information
SF:
First Day at SF:

Last Day at SF:

SF Point of Contact (POC) Name:
SF POC Phone:

SF POC Email:

Do you anticipate internship-related travel within your internship period?*

Yes

No

If yes, please list the anticipated travel dates and destinations:

*Internship related travel does not include initial travel to or return travel from internship. Internship related travel refers to any travel that will occur during the
internship.

SECTION 3 – Location Information
SMART may provide Internship Support Payments for scholars who need to relocate closer to their SF in order to perform their summer internship. Scholar
address is defined as the location that scholars travel from to relocate closer to their SF, if applicable. If you do not need to relocate, please list your summer
residence address below.
Scholar Address* Line 1:
Scholar Address Line 2:
City:

State:

Zip Code:

State:

Zip Code:

SF Address Line 1:
SF Address Line 2:
City:

DD FORM 3067-8, 20220701 DRAFT

PREVIOUS EDITION IS OBSOLETE.

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SECTION 4 – Academic Information
Are you currently on academic probation with the SMART Program?

Yes

No

Do you anticipate that your cumulative GPA will be below a 3.0 at the time of your internship start date?

Yes

No

SECTION 5 – 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 documentation from my SF 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 begin my internship, I must notify the
SMART Program immediately.
I understand that if I receive Internship Support Payments and then do not perform my internship, per to the dates detailed in this request, I
may be responsible for repaying all Internship Support Payments extended on my behalf.
I certify that the Scholar Address provided in section 3 is the location that I will be traveling from in order to relocate (if needed) near the SF
for the purpose of completing an internship.
Scholar Signature

Date Signed (YYYYMMDD)

-------------------- DO NOT WRITE BELOW THIS LINE / SMART SCHOLARSHIP PROGRAM USE ONLY -------------------SECTION 6 – Additional Information/Remarks

NEEDS DD67
SECTION 7 – SMART Program Review
Verified Clearance Status:

Cleared

Verified Academic Standing:

GPA Above 3.0

Interim Eligible

Not Cleared (Action Needed)

GPA Below 3.0 (Action Needed)

Current Cumulative GPA:
Verified Distance Between Scholar Address, per section 3,
and SF:
Distance (in miles):

Eligible for Internship Support Payment
Not Eligible for Internship Support Payment

Verified Internship Support Payment Amount:

$

Internship Length (Number of Weeks):

Total Amount of Internship Support Payment Funding:

per week

Payment 1 Date:

Payment 2 Date:

Payment 3 Date:

Payment 1 Amount: $

Payment 2 Amount: $

Payment 3 Amount: $

Internship Report Due Date:
Reviewed by (Name):

DD FORM 3067-8, 20220701 DRAFT

Date (YYYYMMDD):

PREVIOUS EDITION IS OBSOLETE.

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