Erma Bryd Scholarship Program Applicant Information Form

U.S. DEPARTMENT OF EDUCATION

OFFICE OF POSTSECONDARY EDUCATION

TEACHER AND STUDENT DEVELOPMENT PROGRAMS SERVICE

WASHINGTON, DC 20006-8521

Fiscal Year 2009

APPLICATION FOR NEW AWARDS

ERMA BYRD SCHOLARSHIP PROGRAM

CFDA No. 84.116E

CLOSING DATE: July 13, 2009

DATED MATERIAL – OPEN IMMEDIATELY

OMB No. 1840-NEW-v.1

Exp. 00/00/0000

Paperwork Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The valid OMB control number for this information collection is 1840-NEW-v.1. The time required to complete this information collection is estimated to average 1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington, DC 20202-4651. If you have comments or concerns regarding the status of the individual submission of this form, please contact Lauren Kennedy at 202-502-7630 or ermabyrdprogram@ed.gov.

Table of Contents

Paperwork Burden Statement 1

Table of Contents 1

Dear Applicant: 1

Competition Highlights 1

General Information 1

Instructions for Applying to the Erma Byrd Scholarship Program 1

Instructions for Completing the Applicant Information Form 1

Eligible Fields of Study for the Erma Byrd Scholarship Program 1

Instructions for Transmitting Applications 1

Checklist for Application Package 1

Notice to Applicants: the Government Performance and Results Act (GPRA) 1

Important Notice to Prospective Participants in U.S. Department Of Education Contract and Grant Programs 1

Omnibus Appropriations Act, 2009 1

Privacy Act Statement 1

Erma Byrd Scholarship Program – Applicant Information Form 1

Social Security Number (Applies to Undergraduate Applicants Only) 1

Certification of eligibility for federal assistance in certain programs 1

Erma Byrd Scholarship Program Institutional Agreement 1

Dear Applicant:

I am pleased to provide the application booklet for the Fiscal Year 2009 Erma Byrd Scholarship Program competition. The U.S. Department of Education's Office of Higher Education Programs administers the Erma Byrd Scholarship Program, which is authorized under Title III of the Omnibus Appropriations Act, 2009, Pub.L. 111-8.

The Erma Byrd Scholarship Program provides scholarships to individuals pursuing a course of study that will lead to a career in industrial health and safety occupations, including mine safety. This program is designed to increase the skilled workforce in these fields at both the fundamental skills level and the advanced skills level.

Please note that the Notice Inviting Applications for New Awards published in the Federal Register is the official document describing the requirements for applying for an Erma Byrd Scholarship and provides application submission procedures. Applicants should not rely upon any information that is inconsistent with the guidance contained within the official document.

To be eligible for an Erma Byrd Scholarship, students must be enrolled in an associate’s degree program or within two years of completing a bachelor’s or graduate degree in an eligible field of study at an accredited United States institution of higher education. The applicant must be eligible to receive a federal grant, loan, or work assistance, in accordance with Section 484 of the Higher Education Act of 1965, as amended, and must be a citizen, national, or permanent resident of the United States.

An application will not be considered complete unless all information is provided using the Applicant Information Form found in this booklet. For undergraduate students, scholarships will be awarded first to students who are eligible to receive a Pell grant, in the order that applications are received. If additional funds are available, scholarships will be awarded to undergraduate students who are not Pell eligible in the order that applications are received. For graduate students, scholarships will be awarded in the order that applications are received.

Applicants who wish to be considered for Pell eligibility must complete a Free Application for Federal Student Aid (FAFSA) and must also submit their Social Security Number, using the form contained in this booklet, to the program office via postal mail prior to the competition deadline. Applicants may obtain a copy of the FAFSA at www.fafsa.ed.gov or from their institution’s financial aid office. We encourage applicants to submit their FAFSA electronically, since electronic filing is 7 to 14 days faster than filing via mail.

The Erma Byrd Scholarship Program office is available to assist all applicants and may be reached by e-mail at ermabyrdprogram@ed.gov or by telephone at (202) 502-7630. Please note that all applications must be submitted or postmarked no later than July 13, 2009. The instructions for the transmitting the application can be found in this booklet.

On behalf of the Erma Byrd Scholarship Program and the Department, I wish you every success with your application and in your studies.

Sincerely,

Vickie L. Schray

Acting Deputy Assistant Secretary for Higher Education Programs

Office of Postsecondary Education

Competition Highlights

1. All applications must be submitted no later than July 13, 2009.

2. All Erma Byrd Scholarship recipients must be enrolled or planning to enroll in an accredited, degree-granting program at the associate’s, bachelor’s, or graduate level. For bachelor’s and graduate level recipients, students must be within two years of completing their degree. The scholarship must be used in an eligible field of study as specified in this application package.

3. For undergraduate students, scholarships will be awarded first to students who are eligible to receive a Pell grant, in the order that applications are received. If additional funds are available, scholarships will be awarded to undergraduate students who are not Pell eligible in the order that applications are received. For graduate students, scholarships will be awarded in the order that applications are received.

4. Applicants who wish to be considered for Pell eligibility must do the following:

   1. Submit a Free Application for Federal Student Aid (FAFSA), which may be obtained at www.fafsa.ed.gov or from your institution’s financial aid office.

   2. Submit your Social Security Number to the program office via postal mail prior to the competition deadline, using the form contained in this booklet.

5. Based upon the availability of funds and the scholar’s continued academic progress, the Erma Byrd Scholarship may be renewed once following the initial award. An individual may receive a scholarship for a total of two years, or the time required to complete the degree for which the scholarship was awarded, whichever comes first.

6. Upon completion of their degrees, scholarship recipients will be required to be employed in a career position directly related to industrial health and safety, including mine safety, for a period of one year. A verification of employment report is to be submitted by the scholarship recipient to the Secretary one year after completion of academic study, reporting on post graduation activities. Failure to fulfill the service obligation will result in the scholarship converting to a Direct Student Loan with all the associated repayment conditions, including interest payments and possible penalties for late repayment.

General Information

Applicants can access the FY 2009 Erma Byrd Scholarship Program application by electronically downloading it from the program website at http://www.ed.gov/programs/ermabyrd/index.html.

An applicant who is unable to obtain an electronic copy of the application package may submit a written request to obtain a hardcopy. In the request, the applicant should explain the reason or reasons that prevent the applicant from using the Internet to obtain a copy of the application. If you mail your written statement to the Department, it must be postmarked no later than two weeks before the application deadline date. If you fax your written statement to the Department, we must receive the faxed statement no later than two weeks before the application deadline date.

Address and mail or fax your statement to: Erma Byrd Scholarship Program, U.S. Department of Education, 1990 K Street, N.W., 6^th floor, Washington, DC 20006-8524. Fax: (202) 502-7852.

Individuals with disabilities may obtain the application package in an alternative format (e.g., Braille, large print, audiotape, or computer diskette) by contacting the program office.

To request a Free Application for Student Financial Aid (FAFSA), please contact:

Federal Student Aid Information Center, P.O. Box 84, Washington, DC 20044-0084.

Telephone (toll free): 1 (800) 433-3243; Internet: http://www.fafsa.ed.gov/

If you have any questions regarding the Erma Byrd application, please contact the program office at ermabyrdprogram@ed.gov or 202-502-7630.

Purpose

The Erma Byrd Scholarship Program provides scholarships to individuals pursuing a course of study that will lead to a career in industrial health and safety occupations, including mine safety. This program is designed to increase the skilled workforce in these fields at both the fundamental skills level and the advanced skills level. The program has a service obligation component, requiring recipients of the scholarship to be employed in a career position directly related to industrial health and safety, including mine safety, for a period of one year upon completion of the degree program. The selected areas of study are: mining and mineral engineering, industrial engineering, occupational safety and health technology/technician, quality control technology/technician, industrial safety technology/technician, hazardous materials information systems technology/technician, mining technology/technician, and occupational health and industrial hygiene. Scholarship recipients must begin such employment no more than six months after the completion of their degree program.

Authorization

The Erma Byrd program is established by Title III of the Omnibus Appropriations Act, 2009, Pub.L. 111-8.

Eligible Applicants

Eligibility is limited to individuals who, at the time of application, are: (1) enrolled in an associate’s degree program, or within two years of completing a degree at the bachelor’s or graduate level; (2) eligible to receive a federal grant, loan, or work assistance pursuant to Section 484 of the Higher Education Act of 1965, as amended (HEA); and (3) pursuing an associate’s, bachelor’s or graduate degree in an eligible field of study under the Erma Byrd scholarship program, at an accredited United States institution of higher education. In addition, to be eligible to receive an Erma Byrd scholarship, an individual must be a citizen, national, or permanent resident of the United States.

For undergraduate applicants to the Erma Byrd Scholarship Program, priority will be given first to students who are eligible to receive a Pell grant. Applicants who wish to have Pell eligibility considered as part of their application must demonstrate financial need by 1) submitting a Free Application for Federal Student Aid (FAFSA), which may be obtained at www.fafsa.ed.gov or from your institution’s financial aid office, and 2) submitting your Social Security Number to the program office via postal mail prior to the competition deadline, using the form contained in this booklet. We encourage students to submit the FAFSA electronically since electronic filing is faster (as much as 7 to 14 days faster) than filing a paper FAFSA. The Erma Byrd Scholarship Program has direct access to the financial information provided on each applicant’s FAFSA. The applicant does not need to specify a Federal school code for the Erma Byrd Scholarship Program.

A person is ineligible to apply for this fellowship if he or she has defaulted on a debt to the Federal Government on any previous non-procurement transaction with the Federal Government and has not made satisfactory arrangements to repay a defaulted debt, or has received sentencing under Section 5301 of the Anti-Drug Abuse Act of 1988.

Eligible Fields of Study

The fields eligible for the Erma Byrd Scholarship Program are courses of study leading to the following careers: mining and mineral engineering, industrial engineering, occupational safety and health technology/technician, quality control technology/technician, industrial safety technology/technician, hazardous materials information systems technology/technician, mining technology/technician, and occupational health and industrial hygiene. On the Applicant Information Form, all applicants must specify the eligible field of study in which they desire to have their application evaluated. The applicant must be enrolled or plan to enroll in the degree program for the eligible field of study in which they have applied. Applications submitted for study in fields not listed will be ruled ineligible and will not be reviewed.

Awards

Based upon the availability of funds and the scholar’s continued academic progress, the Erma Byrd Scholarship may be renewed once following the initial award. An individual may receive a scholarship for a total of two years or the time required to complete the degree for which the scholarship was awarded, whichever is less. The award will be paid to the student’s institution on behalf of the scholarship recipient. The disposition of the institutional payment to the student is solely the responsibility of the institution.

The institutions of higher education that Erma Byrd Scholars have chosen to attend administer all awards. In order for a student to receive his or her scholarship, the institution the student is attending must agree to accept the grant and administer the scholarship in compliance with the guidelines governing this program.

Conditions of Award

Scholarship recipients must be enrolled or planning to enroll in an accredited, degree-granting program at the associate’s, bachelor’s, or graduate level. For bachelor’s and graduate level recipients, students must be within two years of completing their degree. The scholarship must be used in an eligible field of study as specified in this application package.

A second year of funding will be provided to students who continue to meet program eligibility requirements, contingent upon: (1) the availability of funds and (2) satisfactory academic progress as determined by the student’s institution. Scholarship recipients are eligible for up to two years of support or until degree completion, whichever comes first.

Scholarship recipients will be required to be employed in a career position directly related to industrial health and safety, including mine safety, for at least one year upon completion of their degree. Scholarship recipients must begin such employment no more than six months after the completion of their degree program. A verification of employment report is to be submitted by the scholarship recipient to the Secretary one year after completion of academic study, reporting on post graduation activities. Failure to fulfill the service obligation will result in the scholarship converting to a Direct Student Loan with all the associated repayment conditions, including interest payments and possible penalties for late repayment.

Restrictions

Erma Byrd Scholarships are portable awards. Requests to change a recipient’s institution or graduate program must be approved in advance by the Secretary of Education. Such requests should be addressed to the Erma Byrd Scholarship Program office.

APPLICATION REVIEW AND SELECTION PROCESS

Applications will be reviewed by Department of Education staff to ensure compliance with program requirements and eligibility criteria. The percentage of applications received in each field of study will determine the number of scholarships awarded in the fields.

Undergraduate Applicants

In selecting undergraduate applicants to receive an Erma Byrd scholarship, priority will be given first to students who are eligible to receive a Pell grant. The Secretary will award scholarships to Pell eligible students in the order that the applications are received. If additional funds are available, scholarships will be awarded to undergraduate students who are not Pell eligible, in the order that their applications are received.

Graduate Applicants

In selecting graduate applicants, the Secretary will award scholarships to students in the order that the applications are received.

Instructions for Applying to the Erma Byrd Scholarship Program

Application requirements for the Erma Byrd Scholarship Program will be strictly enforced. Applications must contain all required materials when submitted to the Department of Education. No exceptions will be made.

A complete application package must consist of the following items or it will not be reviewed:

• Applicant Information Form

Applicants must type all items to complete the Applicant Information Form. The Applicant Information Form is located on page 19 of this booklet. Use the instructions on page 9 of this document to complete each item on the application form. Applicants must remember to sign the form.

• Certifications and Assurances

All applicants must sign the Certification of Eligibility (ED Form 80-0016) by typing their name on the signature line and submitting the form electronically in Microsoft Word (.DOC) format with the application. Certifications sent separately to the Department of Education will not be accepted. Original signatures may be required at a later date.

• Pell Grant Eligibility Certification Sheet (optional)

Undergraduate applicants who wish to have Pell eligibility considered as part of their application package must submit their Social Security Numbers to the program office via postal mail, using the form found in this application package.

NOTE: Failure to provide complete and accurate information necessary to determine eligibility will result in the disqualification of your application. The provision of fraudulent information on your application may result in the withdrawal of an Erma Byrd Scholarship, even after the award has been made.

Instructions for Completing the Applicant Information Form

PRINT OR TYPE.

Item 1. Name: Each applicant must provide his or her last name, first name and middle initial.

Item 2. Current Address and Phone Number: Each applicant must indicate where he or she may be contacted by mail and phone. Applicants should inform the program office of any changes to their current address or phone number.

Item 3. Permanent Address and Phone Number: Each applicant must indicate where they may be contacted by mail or phone at any time. Applicants should inform the program office of any changes to their permanent address or phone number.

Item 4. E-mail Address: Applicants should provide an e-mail address where they may be reached. This e-mail address will be used if we need to contact you regarding your application. Applicants should inform the program office of any changes to their e-mail address.

Item 5. Nationality: Applicants must indicate whether they are citizens, nationals, or permanent residents of the United States.

Item 6. Field of Study Code Number: Each applicant must select a field of study code from the list provided on page 10 of this document. Only the fields listed are eligible for Erma Byrd Scholarships. Applications submitted for fields of study not listed will be ruled ineligible and not reviewed.

Item 7. Name of Institution of Higher Education You are Attending or Plan to Attend: Each applicant must indicate the institution where he or she expects to study as an Erma Byrd Scholar.

Item 8. Degree Completion: Each applicant must indicate the degree he or she expects to pursue as an Erma Byrd Scholar and anticipated graduation date.

Item 9. Educational History: Each applicant must provide a list of all schools attended, in reverse chronological order.

Item 10. Certification: Each applicant must sign his or her name and date the form.

Eligible Fields of Study for the Erma Byrd Scholarship Program

Field Code	Fields Of Study
14.2101	Mining and Mineral Engineering
14.3501	Industrial Engineering
15.0701	Occupational Safety and Health Technology/Technician
15.0702	Quality Control Technology/Technician
15.0703	Industrial Safety Technology/Technician
15.0704	Hazardous Materials Information Systems Technology/Technician
15.0901	Mining Technology/Technician
51.2206	Occupational Health and Industrial Hygiene

Instructions for Transmitting Applications

Applications for grants under this program must be submitted electronically unless an applicant has obtained advance permission to submit a paper application. See below for instructions.

1. Electronic Submission of Applications

All applications must be submitted electronically by e-mailing a Microsoft Word (.DOC) document to ermabyrdprogram@ed.gov. Applications will not be accepted if submitted in any format other than Microsoft Word.

2. Paper Submission of Applications

To request permission to submit a paper application by mail, contact the program office at ermabyrdprogram@ed.gov on or before July 3, 2009. In your request, you must include the reason why you are unable to submit the application electronically.

After the program office has notified you that your request to submit a paper application has been approved, mail your application to the following address on or before the deadline date:

Erma Byrd Scholarship Program (CFDA #84.116E)

Office of Postsecondary Education

U.S. Department of Education

1990 K Street NW, 6^th Floor

Washington, DC 20006

Mailed applications must show proof of mailing on or before the deadline date using one of the following methods:

(1) A legibly dated U.S. Postal Service postmark,

(2) A legible mail receipt with the date of mailing stamped by the U.S. Postal Service,

(3) A dated shipping label, invoice, or receipt from a commercial carrier, or

(4) Any other proof of mailing acceptable to the Secretary of the U.S. Department of Education.

If you mail your application through the U.S. Postal Service, we do not accept either of the following as proof of mailing:

(1) A private metered postmark, or

(2) A mail receipt that is not dated by the U.S. Postal Service.

If your application is postmarked after the application deadline date, we will not consider your application.

Note: The U.S. Postal Service does not uniformly provide a dated postmark. Before relying on this method, you should check with your local post office.

c. Submission of Applications by Hand Delivery

If you submit your application in paper format by hand delivery, you (or a courier service) must deliver the original application, by hand, on or before the application deadline date, to the Department at the following address:

U.S. Department of Education

Application Control Center

Attention: CFDA Number 84.116E

550 12th Street, S.W.

Room 7041, Potomac Center Plaza

Washington, DC 20202-4260

The Application Control Center accepts hand deliveries daily between 8:00 a.m. and 4:30 p.m., Washington, DC time, except Saturdays, Sundays, and Federal holidays.

If you hand deliver your application to the Department--

1. You must indicate on the envelope the CFDA number, including suffix letter, of the competition under which you are submitting your application. The CFDA Number of the Erma Byrd competition is 84.116E.

2. The Application Control Center will mail a grant application receipt acknowledgment to you. If you do not receive the grant application receipt acknowledgment within 15 business days from the application deadline date, you should call the U.S. Department of Education Application Control Center at (202) 245-6288.

4. Accommodations or Auxiliary Aids

Individuals with disabilities who need an accommodation or auxiliary aid in connection with the application process should contact the program office for assistance. If the Department provides an accommodation or auxiliary aid to an individual with a disability in connection with the application process, the individual’s application remains subject to all other requirements and limitations in this notice.

Checklist for Application Package

Does the application include each of the following?

[ ] Applicant Information Form

[ ] Certification of Eligibility Form

[ ] Social Security Number (Optional, undergraduate applicants only)

Notice to Applicants: the Government Performance and Results Act (GPRA)

What is GPRA?

The Government Performance and Results Act of 1993 (GPRA) is a straightforward statute that requires all federal agencies to manage their activities with attention to the consequences of those activities. Each agency is to clearly state what it intends to accomplish, identify the resources required, and periodically report their progress to the Congress. In so doing, it is expected that the GPRA will contribute to improvements in accountability for the expenditures of public funds, improve Congressional decision-making through more objective information on the effectiveness of federal programs, and promote a new government focus on results, service delivery, and customer satisfaction.

How has the Department of Education Responded to the GPRA Requirements?

As required by GPRA, the Department of Education has prepared a strategic plan for 2007-2012. This plan reflects the Department’s priorities and integrates them with its mission and program authorities and describes how the Department will work to improve education for all children and adults in the U.S. The Department’s goals, as listed in the plan, are:

Goal 1: Improve student achievement, with a focus on bringing all students to grade level in reading and mathematics by 2014

Goal 2: Increase the academic achievement of all high school students

Goal 3: Ensure the accessibility, affordability, and accountability of higher education, and better prepare students and adults for employment and future learning.

What are the performance indicators for the Erma Byrd Scholarship Program?

The performance indicators for the Erma Byrd Scholarship Program are part of the Department’s plan for meeting Goal 3. The specific goal for the Erma Byrd Scholarship Program is to increase the skilled workforce in industrial health and safety occupations, including mine safety. The effectiveness of the Program will be measured by:

1. graduation completion rates

2. time-to-degree completion rates

3. percentage of students fulfilling the service obligation within eighteen months of graduating.

How does the Department of Education determine whether performance goals have been met?

As a condition of the award, a verification of employment report is to be submitted by the scholarship recipient to the Secretary one year after completion of academic study, reporting on post graduation activities. This report will document the extent to which project goals and objectives are met.

OMB No. 1840-0562

Exp. 08/31/2009

Important Notice to Prospective Participants in U.S. Department Of Education Contract and Grant Programs

GRANTS

Applicants for grants from the U.S. Department of Education (ED) have to compete for limited funds. Deadlines assure all applicants that they will be treated fairly and equally, without last minute haste. For these reasons, ED must set strict deadlines for grant applications. Prospective applicants can avoid disappointment if they understand that:

Failure to meet a deadline will mean that an applicant will be rejected without any consideration whatever.

The rules, including the deadline for applying for each grant, are published individually in the Federal Register. A one-year subscription to the Register may be obtained by sending $340.00 to: Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402-9371. (Send check or money order only, no cash or stamps.)

The instructions in the Federal Register must be followed exactly. Do not accept any other advice you may receive. No ED employee is authorized to extend any deadline published in the Register.

Questions regarding submission of applications may be addressed to:

U.S. Department of Education

Application Control Center

550 12^th Street, S.W.

Room 7041

Washington, DC 20202-4260

CONTRACTS

Competitive procurement actions undertaken by the ED are governed by the Federal Procurement Regulation and implementing ED Procurement Regulation.

Generally, prospective competitive procurement actions are synopsized in the Commerce Business Daily (CBD). Prospective offerors are therein advised of the nature of the procurement and where to apply for copies of the Request for Proposals (RFPOfferors are advised to be guided solely by the contents of the CBD synopsis and the instructions contained in the RFP. Questions regarding the submission of offers should be addressed to the Contracts Specialist identified on the face page of the RFP.

Offers are judged in competition with others, and failure to conform with any substantive requirements of the RFP will result in rejection of the offer without any consideration whatever.

Do not accept any advice you receive that is contrary to instructions contained in either the CBD synopsis or the RFP. No ED employee is authorized to consider a proposal, which is non-responsive to the RFP.

A subscription to the CBD is available for $208.00 per year via second class mailing or $261.00 per year via first class mailing. Information included in the Federal Acquisition Regulation is contained in Title 48, Code of Federal Regulations, Chapter 1 ($49.00). The foregoing publication may be obtained by sending your check or money order only, no cash or stamps, to:

Superintendent of Documents

U.S. Government Printing Office

Washington, DC 20402-9371

In an effort to be certain this important information is widely disseminated, this notice is being included in all ED mail to the public. You may therefore, receive more than one notice. If you do, we apologize for any annoyance it may cause you. ED FORM 5348, 8/92

REPLACES ED FORM 5348, 6/86 WHICH IS OBSOLETE

Omnibus Appropriations Act, 2009

Provided further, That $1,000,000, to remain available until expended, shall be available to carry out a scholarship program for the purpose of increasing the skilled workforce for industrial health and safety occupations, including mine safety: Provided further, That the Secretary of Education shall identify these scholarships as ‘Erma Byrd Scholarships’: Provided further, That such scholarships shall be awarded without regard to an applicant’s prior work experience, but the Secretary shall, notwithstanding section 437 of the General Education Provisions Act and 5 U.S.C. 553, by notice in the Federal Register, establish the eligibility requirements, service obligations, payback requirements, and other program requirements similar to those specified in section 515 of the Federal Mine Safety and Health Act as are necessary to implement such a program: Provided further, That such scholarship funds may be used to replace a student’s expected family contribution, but institutions accepting such scholarship funds may not use these funds to supplant existing institutional aid: Provided further, That the Secretary shall be authorized to accept contributions for such scholarships from private sources: Provided further, That these funds shall be used for scholarships for academic year 2009-2010 and may be available for scholarships in academic year 2010-2011

Privacy Act Statement

In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that: (1) The Department is authorized to collect information to implement the Erma Byrd Scholarship Program under Title III of the Omnibus Appropriations Act, 2009. In accordance with this authority, the Office receives and maintains personal information on applicants for use in processing applications and selecting participants. (2) The principal purpose for collecting this information is to administer the program, including use by program staff to determine eligibility and to select scholarship recipients. Disclosure may be made to a Congressional office from the record of an individual in response to any inquiry from the Congressional office made at the request of that individual. If the Department or an employee of the Department is involved in litigation, the Department may send your information to the Department of Justice, a court, adjudicative body, individual or entity empowered by the Department to resolve disputes, counsel or representative or potential witness such disclosure is compatible witness provided such disclosure is compatible with purpose for which the information was requested. Disclosure may also be made to the Department of Justice for the purpose of obtaining its advice as whether particular records are required to be disclosed under the Freedom of Information Act. When the appropriate office of ED determines that an individual or an organization is qualified to carry out specific research, that official may disclose information to that researcher solely for the purpose of carrying out the research. When ED contracts with a private firm for the purpose of administering the program, relevant records will be disclosed to the contractor. The contractor shall be required to maintain Privacy Act safeguards with respect to such records. Information may be disclosed to any Federal, State, local, or foreign agency or public authority responsible for enforcing, investigating, or prosecuting violations of administrative, civil, or criminal law or regulation where that information is relevant to any enforcement, regulatory, investigative, or prosecutive responsibility with the receiving entity’s jurisdiction. (3) You are not required to submit the information requested in this application, however the information will be used in the processing and evaluation of applications; and the failure to provide all or any part of the requested information may delay the process or make it impossible to process an application (disclosure of your social security number is voluntary; failure to disclosure such number will not result in the denial of any right, benefit, or privilege to which an individual may be entitled).

FORMS TO BE FILLED OUT BY APPLICANT

Erma Byrd Scholarship Program – Applicant Information Form (Refer to page 9 for instructions for completion)
1.				Last Name:	First Name:			MI:
2. Current Street Address (Include city, state, and zip code) Current Phone:
3.		Permanent Street Address (Include city, state, and zip code):					Permanent Phone:
4.		E-mail Address:
5.		Nationality (Mark appropriate response):
		____ U.S. Citizen ____ U.S. National ____ Permanent Resident of the U.S. ____ None of the above
6.		Field of Study (Use ONE code only):

7.		Name of Institution of Higher Education You are Attending or Plan to Attend:
8.		Degree Completion (Please indicate the degree you expect to pursue as an Erma Byrd Scholar):
	_	_____ Graduate _____ Bachelor’s _____ Associate’s
		Anticipated Graduation Date ________________ (month/year)
9.		Educational History (Please list all schools you have attended in reverse chronological order, beginning with your current or most recently attended school):
		1. 2. 3.

10. Certification: I hereby certify that the above information is complete, truthful, and accurate.

____________________________________ _______________________

Signature Date

Pell Grant Eligibility Certification Sheet (Applies to Undergraduate Applicants Only)

For undergraduate applicants to the Erma Byrd Scholarship Program, priority will be given first to students who are eligible to receive a Pell grant. Applicants who wish to have Pell eligibility considered as part of their application must demonstrate financial need by 1) submitting a Free Application for Federal Student Aid (FAFSA), which may be obtained at www.fafsa.ed.gov or from your institution’s financial aid office, and 2) submitting your Social Security Number to the program office via postal mail prior to the competition deadline, using this form.

We encourage students to submit the FAFSA electronically since electronic filing is faster (as much as 7 to 14 days faster) than filing a paper FAFSA. The Erma Byrd Scholarship Program has direct access to the financial information provided on each applicant’s FAFSA. The applicant does not need to specify a Federal school code for the Erma Byrd Scholarship Program.

If you wish to have financial need considered as part of your application, please fill out this form (print or type) and submit via postal mail to the address below on or before the deadline date:

Erma Byrd Scholarship Program

Office of Postsecondary Education

U.S. Department of Education

1990 K Street NW, 6^th Floor

Washington, DC 20006

Please be advised that the U.S. Department of Education will treat your Social Security Number in strict confidence.

Name (Last, First, MI): _________________________________________

Current Address: _________________________________________

_________________________________________

_________________________________________

Social Security Number: _________________________________________

Certification of eligibility for federal assistance in certain programs

I understand that 34 CFR 75.60, 75.61, and 75.62 require that I make specific certifications of eligibility to the U.S. Department of Education (ED) as a condition of applying for Federal funds in certain programs and that these requirements are in addition to any other eligibility requirements that ED imposes under program regulations. Under 34 CFR 75.60 – 75.62:

1. I certify that:

1. I do not owe a debt, or I am current in repaying a debt, or I am not in default (as that term is used at 34 CFR Part 668) on a debt:

1. To the Federal Government under a nonprocurement transaction (e.g., a previous loan, scholarship, grant, or cooperative agreement); or

2. For a fellowship, scholarship, stipend, discretionary grant, or loan in any program of ED that is subject to 34 CFR 75.60, 75.61, and 75.62, including:

• Federal Pell Grant Program (20 U.S.C. 1070a, et seq.);*

• Federal Supplemental Educational Opportunity Grant (FSEOG) Program (20 U.S.C. 1070(b), et seq.):*

• Leveraging Educational Assistance Partnership (LEAP) 20 U.S.C. 1070c, et seq.);*

• Federal Perkins Loan Program (20 U.S.C. 1087aa, et seq.);*

• Federal Family Education Loan (FFEL) Program (20 U.S.C. 1071, et seq.);*

• William D. Ford Federal Direct Loan Program (20 U.S.C. 1087a, et. seq.);

• Robert C. Byrd Honors Scholarship Program (20 U.S.C. 1070d-31, et seq.);

• Jacob K. Javits Fellows Program (20 U.S.C. 1134-1134d);

• Bilingual Education Fellowship Program (20 U.S.C. 3221-3262);

• Rehabilitation Long-Term Training Program (29 U.S.C. 774(b));

• Teacher Quality Enhancement Grants Program (20 U.S.C. 1021, et seq.);

OR

2. I have made arrangements satisfactory to ED to repay a debt as described in A.1. or A.2. (above) on which I had not been current in repaying or on which I was in default (as that term is used in 34 CFR Part 668).

2. I certify also that I have not been declared by a judge, as a condition of sentencing under section 5301 of the Anti-Drug Abuse Act of 1988 (21 U.S.C. 862), ineligible to receive Federal assistance for the period of this requested funding.

I understand that providing a false certification to any of the statements above makes me liable for repayment to ED for funds received on the basis of this certification, for civil penalties, and for criminal prosecution under 18 U.S.C. 1001.

_______________________________________ _____________________________

(signature) (Date)

_______________________________________

(typed or printed name)

Name or number of ED program under which this certification is being made: Erma Byrd Scholarship Program

NOTE: Signing this document means that you do not owe a debt, or are current in repaying a debt, or are not in default to the following Student Financial Assistance Programs: Federal Pell Grants, Federal Supplemental Educational Opportunity Grants, Leveraging Educational Assistance Partnership, Federal Perkins Loans, Federal Family Education Loans, William D. Ford Federal Direct Loans.

ED 80-0016 (Revised 8/01)

FORMS TO BE FILLED OUT BY INSTITUTION

After scholarship recipients are selected, the Erma Byrd Scholarship Program Institutional Agreement will be provided to the institutions they designate in order to obtain agreement that the student’s institution will disburse scholarship funds in accordance with program guidelines.

Erma Byrd Scholarship Program Institutional Agreement

[Name of student] has been selected to receive a scholarship provided by the Erma Byrd Scholarship Program and has submitted the name of your institution as the institution he/she will attend in Fall 2009. The Erma Byrd Scholarship Program, which was created by the Omnibus Appropriations Act of 2009, provides up to two years of scholarship funding to individuals who are obtaining a degree in a program of study that will lead to a career in industrial health and safety occupations or related fields, including mine safety. As a condition of that scholarship, the student must be enrolled in an accredited, degree-granting U.S. institution where he or she is in good academic standing in one of the fields deemed eligible for this program. Scholarship recipients must be within two years of completion of their degrees and are required to be employed in a career position directly related to industrial health and safety, including mine safety, for one year upon completion of their degrees.

Erma Byrd Scholarships may be used at any accredited institution of higher education in the United States that agrees to accept the grant and to administer the scholarship according to program guidelines. Scholarship funds may be used to replace a student’s expected family contribution, but institutions accepting such scholarship funds may not use these funds to supplant existing institutional aid. Please note that although individual students are the applicants for this fellowship program, the grant award itself is an institutional grant, and the institution is the official grantee. The U.S. Department of Education makes a grant award to the institution, which then disburses funding to scholarship recipients according to the policies and procedures established by university administrators. For students who wish to renew their award for a second year, institutions will be asked to certify the students’ continued enrollment in an eligible field of study and their satisfactory academic progress before renewal awards are made.

This agreement certifies that the student named above meets program eligibility requirements and will be used to verify information provided on his/her application. In addition, this agreement certifies your institution’s willingness and ability to accept and disburse Erma Byrd Scholarship Program funds in accordance with program guidelines. We ask that you furnish all of the requested information and return this completed form via e-mail, fax, or postal mail by July 31, 2009 to:

Erma Byrd Scholarship Program

Office of Postsecondary Education

U.S. Department of Education

1990 K Street N.W., 6th floor

Washington, DC 20006-8526

Fax: 202-502-7852

E-mail: ermabyrdprogram@ed.gov

If you have any questions about the form, please contact the program office at ermabyrdprogram@ed.gov or 202-502-7630. Thank you for your assistance.

Section I: Erma Byrd Scholarship Recipient

1. Name of scholarship recipient:

Last name First name Middle initial

2. Intended degree (check one):

Associate’s Bachelor’s Graduate

Expected graduation date (month/year):

Field of Study: ______________________________

Is this student in good academic standing at your institution? ______Yes ______ No

If no, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 Section II: Institutional Agreement

Upon the institution’s acceptance of the scholarship recipient, and agreement to accept and administer the Erma Byrd Scholarship according to program guidelines, our office will send a Grant Award Notification and Loan Agreement to the institution on the fellow’s behalf.  It is the institution’s responsibility to obtain the student’s signature on the Loan Agreement (describing actions that will be taken if a student fails to meet the terms of the scholarship, including the post-graduation service obligation) and return this document to the program office, at which time funds will be disbursed. Please contact the program office immediately should the institution experience difficulty in the establishment of the grant award account for any recipient, so that our office may provide timely guidance.

On behalf of your institution, please indicate acceptance of the Erma Byrd Scholarship on behalf of the student named above and agreement to administer the scholarship according to the terms and conditions in the program guidelines.  If the institution does not wish to accept this scholarship, please notify the program office as soon as possible, so that we may notify the student.  The Erma Byrd Scholarship is a portable award, so a recipient may opt to utilize it at another institution.  Only acceptance in writing constitutes official acceptance of the scholarship award for our records. 

 

This certifies that _________________________________________(name of institution) agrees that it will comply with the statute (Omnibus Appropriations Act, 2009) and program guidelines in implementing the Erma Byrd Scholarship Program.

If the institution agrees to accept the scholarship award, please provide the following information with the notification of acceptance:

1. Name of institution ______________________________________________________

2. Contact person ______________________________________________________

3. Phone number ______________________________________________________

4. Fax number ______________________________________________________

5. E-mail address ______________________________________________________

6. Mailing address for ______________________________________________________

all grant award

documentation ______________________________________________________

______________________________________________________

7. DUNS number ______________________________________________________

(NOTE:  The 9-digit DUNS number acts as the institution’s identification number, and it facilitates the electronic transmission of grant award funding to your school.  If you do not know this number, please contact your Office of Sponsored Projects/Research/Grants/ Contracts/ Fellowships to acquire it.)

The authorized official identified below has reviewed all information provided and certifies that this document is accurate and complete.

Signature of Authorized Official

Name of Authorized Official Date

2