Candidate Control Form

CANDIDATE CONTROL FORM Please type or print, using black or blue ink. STATE OF LEGAL RESIDENCE

1. Legal name Title First MI Last Suffix

Permanent address 1

Permanent address 2

City State ZIP Code+4

Province Country Foreign ZIP

2. Gender Male Female

3. Do you attend school in a state or country other than your state of legal residence? If so, please enter:

State/country of school attendance

4. Do you live outside of the 50 United States, District of Columbia, or Puerto Rico? Yes No

If so, how long have you lived in this location?

If your state of legal residence and permanent address differ, or you answered yes to either 3 or 4, call 319/341-2777 or email PSP@act.org before continuing. This may affect your status as a candidate for the program.

5. Telephone (_____) ______-__________ Foreign phone

6. DOB _____/_____/_____ Age

7. SSN _______-_______-________

8. Contact information where you can be reached until June 20, if different from those provided above:

Mailing address 1

Mailing address 2

City State ZIP Code

Province Country Foreign ZIP

Telephone (_____) ______-__________ Foreign phone

9. E-mail

10. High school

High school address 1

High school address 2

City State ZIP Code

11. On the line below, print your informal name (including your last name) as you would want it to appear on a name tag. Consider how you would want to be addressed by fellow Presidential Scholars.

First MI Last Suffix

12. On the line below, print your name as you would want it to appear on a Presidential Scholar medallion. This information cannot be revised at a later date.

First MI Last Suffix

13. Name the educator who has influenced you most significantly during your school years and whom you would like honored. This information should be the same as that provided on page 6 of your Supporting Information Form.

Teacher name Title First MI Last Suffix

Teacher school

Teacher school address 1

Teacher school address 2

City State ZIP Code

Teacher’s primary subject area

Teacher home address 1

Teacher home address 2

City State ZIP Code

Province Country Foreign ZIP

OMB No. 1860-0504 – Approved for use through 10/31/12

SUPPORTING INFORMATION FOR THE 2012 PRESIDENTIAL SCHOLARS PROGRAM

PRIVACY ACT ADVISORY STATEMENT

The Privacy Act of 1974 (P.L. 93-579) requires that you be given certain information in connection with this request for information. Accordingly, pursuant to the requirements for the Act, please be advised:

1. The authority for the collection of these data is Executive Order 11155.

2. Furnishing the information requested is voluntary.

3. The data will be used for selection of Presidential Scholars, engraving of Scholar medallions, and arranging transportation and accommodations for Scholars.

4. Other routine uses of the data are for preparation of the Presidential Scholars Yearbook, public affairs, and press releases to new media.

5. Failure to complete the form will mean that you cannot be included among those candidates being considered for designation as Presidential Scholar.

AFFIRMATION OF CANDIDACY

AND AUTHORIZATION FOR RELEASE OF INFORMATION

I, (Full name) , understand that I am a candidate for the honor of Presidential Scholar, have read the Privacy Act Advisory Statement, and affirm my wish to be considered. In the event I am named a Presidential Scholar, permission is hereby given for the release of materials submitted by me for the use of the Commission on Presidential Scholars and the Department of Education as may be deemed appropriate for purposes of the Presidential Scholars Program. I further consent to the release of photographs which may be taken of me, by or for the U.S. Department of Education in connection with the Program. I am (check one) willing unwilling to appear on radio and/or television if such arrangements can be made by the U.S. Department of Education in connection with the Presidential Scholars Program.

Student’s signature Date

Parent’s or legal guardian’s signature Date

CANDIDATE’S BIOGRAPHICAL QUESTIONNAIRE

Note: The selection of award recipients will be influenced by the completeness, neatness, and legibility of replies. Please type or print, in black or blue ink. Font size must be 11 points or larger. Confine your answers to the space provided; do not attach additional pages.

1. Biographical Information

Sex: Male Female

Legal name in full (Print/Type) Last First MI

Permanent home address Street City ST

Telephone (_____) ______-__________ DOB _____/_____/_____ Age

Paperwork Burden Statement

Public 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. Public reporting burden for this collection of information is estimated to average 16 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit under E.O. 11155 and E.O. 12158. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20202-4537 or email ICDocketMgr@ed.gov and reference the OMB Control Number 1860-0504. Note: Please do not return the completed Presidential Scholars application.

Education

1. Name of high school currently attending

City State/Country ZIP Code

SAT: Verbal/Critical Reading Math Writing Test Date

ACT: English Math Reading Science Writing Composite Test Date

2. List any other schools that you attended in the last four years in order of attendance, with the most recent one first.

   	Name of school	Location (city and state)	Dates of attendance

3. List any advanced or special program, courses, or summer courses you have taken that would not be listed on your transcript. List the most recent first. Do not list AP or honors courses here; they will appear on your transcript.

   	Course or program	Name of school	Location (city and state)	Dates of attendance	Hours per week

4. Name of first-choice college or university

City State

5. What course of study (major) would you like to pursue in college? (You may indicate more than one or answer “undecided.”)

6. Do you plan to go to graduate or professional school?

7. Have you made any career decisions? Yes No

If yes, specify:

2. Activities and Work Experiences

1. List activities in which you have participated in your school (such as academics, publications, debating, dramatics, sports, music, art, student government, and clubs). Place an “X” in front of those activities you consider most important. Dates must be in the format MM/DD/YYYY. Estimate dates as best you can.

	Activity	Dates of participation	Hours per week	Offices held	Special awards or honors

OMB No. 1860-0504

Approved for use through 10/31/12

Name (Print/Type)

2. List any special talents (in areas such as music, the arts, sports, published writing or scientific research) that you pursue outside of school.

   	Talent or activity	Periods of participation	Special honors, recognition, or awards

3. List community activities in which you have participated without pay (such as hospital volunteer, religious work, drug/teen/homework hotlines, or outreach programs).

   	Type of work	Name of agency or organization	Dates of participation	Hours per week	Special awards

4. List jobs you have held in the past three or four years. Use separate lines for summer and school year employment.

	Job and type of work	Employer	Sum-mer	School year	Approximate dates of employment	Approximate number of hours per week

OMB No. 1860-0504

Approved for use through 10/31/12

Note: Please be concise. Limit your responses to the spaces provided. Feel welcome to word-process your responses and then paste them on this form. Font size must be 11 points or larger. Do not attach additional pages.

3. Candidate’s Self Assessment

1. Describe any characteristics of your family or your community that have been important to your personal development.

2. Discuss some creative work that illustrates the way you see the world and the way you see yourself in the world. The work may be a scientific theory, novel, film, poem, song, or other art form.

OMB No. 1860-0504

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Name (Print/Type)

3. What is the most significant contribution that you feel you have made to your community’s well-being or the well-being of an individual or individuals in your community? Why were you motivated to do this? What effect do you think it has had on that person or the community?

4. Describe a mistake you made or a challenge you faced. How did you respond to that mistake or challenge, and what did you learn from your experience?

OMB No. 1860-0504

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4. Name the teacher or instructor who has influenced you most significantly during your school years and whom you would like honored. (Note: Should you become a Presidential Scholar, the teacher you name will be invited to Washington, D.C., and honored for his or her accomplishments. Please be sure to print or type the teacher’s name clearly.)

Teacher name Title First MI Last

Teacher’s school:

Name

City ST ZIP Code

Teacher’s primary subject area

Explain the reason for your selection.

Please proofread your responses and review this form to make sure you have answered all questions completely. By signing this document you are certifying that all information contained in your application is accurate and correct, and that you have read the “Important Submission Requirements” document posted on the Presidential Scholars Program website with the downloadable application materials.

Date Signature

This form must be returned to:

Presidential Scholars Program / 59

101 ACT Drive, P.O. Box 4030

Iowa City, IA 52243-4030

and RECEIVED no later than February 23, 2012

OMB No. 1860-0504

Approved for use through 10/31/12

CANDIDATE ESSAY

Name State

Topic: Please attach a photograph of something that or someone who has great significance to you. Explain that significance. Note: If you are visually impaired, you are not required to attach a photograph. Please write about something that or someone who has great significance to you.

Your essay should demonstrate style, depth and breadth of your knowledge, and individuality. Confine your response to the front and back of this page. The photograph must be stapled to this page and must not be larger than 5” x 7”. Photographs will not be returned. Typewritten essays are preferable. Font size must be 11 points or larger. If not typed, please print, using black or blue ink.

OMB No. 1860-0504

Approved for use through 10/31/12

OMB No. 1860-0504

Approved for use through 10/31/12

PRESIDENTIAL SCHOLARS PROGRAM VOLUNTARY SURVEY FORM

The following information is requested on a voluntary basis. The information will be used for statistical purposes only and will remain confidential.

Please check one:

Hispanic or Latino

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Not Hispanic or Latino

Check the box next to the race(s) with which you most closely identify. You may choose all that apply.

American Indian or Alaska Native

A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian

A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American

A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander

A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White

A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Do you consider yourself to be physically challenged or disabled? Yes No

If so, please briefly describe your disability:

OMB No. 1860-0504

Approved for use through 10/31/12

2012 PRESIDENTIAL SCHOLARS PROGRAM SECONDARY SCHOOL REPORT

Legal name of student Last First MI

To comply with the provisions of the Family Educational Rights and Privacy Act of 1974, a school must obtain signed authorization before it can release student information for use in this program.

Permission is hereby given to school officials to release the secondary school record and other requested information for the student named above for consideration in this award program.

Student’s signature Date

Parent’s or legal guardian’s signature Date

If you have attended this school for less than two years, you may copy this form and request someone from your former school to also complete a copy for you.

School Name City ST ZIP Code Phone

Important Instructions for Evaluator and Principal:

1. The student named above is a candidate for the honor of Presidential Scholar. Please provide thorough and complete responses to the questions on this form. Incomplete or limited answers will place your student at a disadvantage. If you complete this form by hand, please write legibly using black or blue ink.

2. Do not submit a letter of recommendation as a replacement for this form. All extraneous material, including letters of recommendation, are removed from candidates’ files and will not be included with the application for review.

If you submit a letter of recommendation, your student’s application will be reviewed as it stands without the letter of recommendation, placing your student at a disadvantage. If you wish, you may cut/copy and paste your answers to the questions on this form from a letter of recommendation.

3. In order to process this student’s application, we must receive

• this completed form;

• a 7-semester secondary school transcript, including grades 9-12 (must be sent in hard copy),

• SAT/ACT scores and any AP test scores (copies are accepted; need not be official); and

• a school profile, if available.

4. Both the evaluator and the principal must sign this form on page 4. Seal the signed form, transcript, test scores, and school profile in an envelope. A school official’s signature must appear across the envelope seal for it to be accepted by the Commission. Return the signed envelope to the student for submission with his or her application materials, in time to meet the RECEIPT deadline noted below. If you need assistance with this requirement, call 319/341-2777 8:30 am – 5:00 pm Central Time.

All application materials, including this form and transcripts, must be received by 5:00 p.m. Central Time, February 23, 2012. Any application materials not received by that deadline will render the student’s application ineligible for review, regardless of who sends them.

OMB No. 1860-0504

Approved for use through 10/31/12

* Items A-F are required and must be completed by a school official (Counselor, Principal, etc.).

1. Name of principal Last First MI

2. Are you confident that the student will receive a school diploma during the current academic year?

Yes No If no, please explain.

3. Expected date of graduation Month / Year

4. Student’s class rank Number of students in class School does not rank students.

5. Student’s grade point average on a point scale, based on semesters.

6. Number of AP courses your school offers: Number this student will have taken by graduation:

AP exams taken and results:

7. Who is evaluating the student on the following pages?

Name Relationship to student (e.g., Teacher/Counselor)

Length of relationship If teacher, please state subject(s)

In items H-O, please be concise. Use examples to support your comments. Limit your response to the space provided.

8. What economic or social conditions characterize your community and most of the parents of the children in your school? (For example, is your community a university town, a mill town, a farming area?)

9. Considering this student’s interests, work habits, and life goals, what is your assessment of the chances that the student will be motivated to take advantage of the opportunities available in college? Please give reasons for your assessment.

OMB No. 1860-0504

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10. Does your school have a service requirement? Yes No If yes, number of hours and type of service required:

This student has exceeded met not met the service requirement.

What special features are part of your school’s curriculum (e.g. AP and honors courses, college study, independent study)? Has the student taken advantage of the most challenging opportunities your school has to offer?

11. Has this student given any strong evidence of leadership ability? Yes No

Please explain the criteria on which you base your judgment and how the student meets those criteria. Include a discussion of the student’s principal strength.

12. Describe how this student demonstrates strong character (e.g. integrity, independence, loyalty, patriotism, self-discipline, employment responsibilities, willingness to work hard, kindness, commitment to high ideals, and caring for others).

OMB No. 1860-0504

Approved for use through 10/31/12

13. Has the student shown exceptional talent or originality in any specific field such as art, music, science, literature, or mathematics? Yes No Please cite examples.

14. Is there anything else about this student you feel is important for the Commission to know that is not likely to appear in the student’s application or transcript – additional qualities, anecdotes, circumstances, or background that would give the Commission insight into this individual?

15. What areas, academic or otherwise, have most challenged this student?

Date Evaluator’s Signature Title

Date Principal’s Signature Title

After completing this form, attach the candidate’s transcript, test scores, and a copy of your school profile, and seal them all in an envelope. Sign your name across the seal and return the envelope to the student for submission with his/her application materials per the deadline noted on Page 1 of this form. If you need assistance with this requirement, please call 319/341-2777, 8:30 am – 5:00 pm Central Time.

OMB 1860-0504

Approved for use through 10/31/12