Candidate Control Form

CANDIDATE CONTROL FORM
1. Legal name

Title

Please type or print, using black or blue ink.

First

MI

STATE OF LEGAL RESIDENCE

Last

Suffix

Permanent address 1
Permanent address 2
City

State

Province
2. Gender

ZIP Code+4

Country
Male

Foreign ZIP

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 319/688-4345 or
email PSP@act.org before continuing. This may affect your status as a candidate for the program.

5. Telephone (_____) ______-__________
6. DOB _____/_____/_____

Foreign phone
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.

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

First
13.

MI

Last

Suffix

Last

Suffix

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

State

ZIP Code

Teacher’s primary subject area
Teacher home address 1
Teacher home address 2
City
Province

Country

Foreign ZIP
OMB No. 1860-0504 – Approved for use through 7/31/15

SUPPORTING INFORMATION FOR THE 2015 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.
A. Biographical Information
Sex: Male

Female

Legal name in full (Print/Type) Last
Permanent home address Street
Telephone (_____) ______-__________

First
City

DOB _____/_____/_____

MI
ST

Age

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 1860-0504. The time
required to complete this information collection is estimated to average 16 hours 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 or suggestions for improving this form, please write to: U.S. Department of Education, Washington, D.C. 202024651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to Presidential
Scholars Program, U.S. Department of Education, 400 Maryland Avenue SW, Washington, D.C. 20202-8173.
OMB No. 1860-0504
Approved for use through 7/31/15

B. Education
1.

Name of high school currently attending
City

State/Country

SAT: Verbal/Critical Reading
ACT: English
2.

Math

ZIP Code

Math
Reading

Writing
Science

Writing

Test Date
Composite

Test Date

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

1.
2.
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

1.
2.
4.

Name of first-choice college or university
City

5.

State

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:
C. 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

1.
2.
3.
4.
5.
6.
7.
8.
OMB No. 1860-0504
Approved for use through 7/31/15

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

1.
2.
3.
4.
5.
6.
7.
8.

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

1.
2.
3.
4.
5.
6.
7.
8.

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

Summer

School Approximate dates Approximate number of
of employment
hours per week
year

1.
2.
3.
4.
5.
6.
7.
8.
OMB No. 1860-0504
Approved for use through 7/31/15

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.
D. 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
Approved for use through 7/31/15

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
Approved for use through 7/31/15

E. Name the teacher or instructor who has influenced you most significantly during your school years and whom you would like
honored. 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 U.S. Presidential Scholars Program website
with the downloadable application materials.
Date

Signature

This form must be returned to:
U.S. Presidential Scholars Program
327 2nd St., Suite 103
Coralville, IA 52241
and RECEIVED no later than February 26, 2015
OMB No. 1860-0504
Approved for use through 7/31/15

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 side
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 7/31/15

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 7/31/15

2015 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 319/688-4345, 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 26, 2015. 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 7/31/15

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

First

MI

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

No

If no, please explain.

C. Expected date of graduation Month
D. Student’s class rank

/ Year
Number of students in class

E. Student’s grade point average

on a

F. Number of AP courses your school offers:

School does not rank students.
point scale, based on

semesters.

Number this student will have taken by graduation:

AP exams taken and results:
G. Who is evaluating the student on the following pages?
Name
Length of relationship

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

I.

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
Approved for use through 7/31/15

J.

Does your school have a service requirement?

This student has exceeded

met

not met

Yes

No

If yes, number of hours and type of service required:

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?

K. 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.

L. 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 7/31/15

M. 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.

N. 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?

O. 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 319/688-4345, 8:30 am – 5:00 pm Central Time.
OMB 1860-0504
Approved for use through 7/31/15