CG-5687 (07/17) Coast Guard Exchange System Scholarship Program Applicat

DEPARTMENT OF HOMELAND SECURITY

OMB No. 1625-0119

U.S. Coast Guard
Expires: 05/31/2017
COAST GUARD EXCHANGE SYSTEM SCHOLARSHIP PROGRAM APPLICATION
APPLICANT INFORMATION
NAME

BIRTH DATE

ADDRESS

PHONE
EMAIL

HIGH SCHOOL DATA
HIGH SCHOOL

CITY

WILL YOU GRADUATE FROM HIGH SCHOOL THIS YEAR?

EXPECTED HIGH SCHOOL GRADUATION DATE

YES

NO

STATE

MONTH:

The following documents must be submitted before the deadline:

YEAR:

Cumulative unweighted GPA (convert on a 4.0 basis):

High School transcript enclosed:

YES

NO

Essay enclosed:

YES

NO

Two letters of recommendation enclosed:

YES

NO

YES

NO

S.A.T. or A.C.T. scores included on transcript:
(If not, have testing agency forward the scores directly to the CGES
Scholarship Committee.)
INTENDED COLLEGE
INTENDED DEGREE MAJOR

STATE
MINOR

HIGH SCHOOL EXTRA CURRICULAR ACTIVITIES
Please provide information that relates to activities occurring during high school and include dates. You may attach a resume highlighting your activities.

CG-5687 (07/17)

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COMMUNITY/VOLUNTEER ACTIVITIES
Please provide information that relates to community activities occurring during the last four years and include dates. You may attach a resume
highlighting your activities.

COAST GUARD PARENT/GUARDIAN INFORMATION
LAST NAME

FIRST NAME

RANK/POSITION

MIDDLE INITIAL
CG EMPLOYEE ID

CHECK APPLICABLE CATEGORY:
CG ACTIVE DUTY

CG RESERVE

CG MILITARY RETIREE

CG AUXILIARIST

CURRENT CG CIVILIAN

COAST GUARD UNIT
CITY

STATE

DAYTIME PHONE NO.

APPLICANT/PARENT/GUARDIAN CERTIFICATION
WE CERTIFY THAT, TO THE BEST OF OUR KNOWLEDGE, ALL RESPONSES ARE TRUE AND FACTUAL, THE PARENT/GUARDIAN, AS WELL AS
THE APPLICANT, HAS REVIEWED THE ELIGIBILITY REQUIREMENTS.
____________________________________________
SIGNATURE OF APPLICANT

_________________________ ____________________________________________
DATE
PRINT NAME

____________________________________________
SIGNATURE OF PARENT/GUARDIAN

_________________________ ____________________________________________
DATE
PRINT NAME

5 U.S.C. 552(a) PRIVACY ACT
AUTHORITY: 14 U.S.C. 531; and 44 U.S.C. 3101.
PURPOSE: To collect academic information for the purpose of evaluating and processing Coast Guard Exchange System (CGES) Scholarship
applications.
ROUTINE USES: Information will be used by CGES selection panel members to evaluate and process CGES Scholarship applications. Any external
disclosures of data within this record will be made in accordance with DHS/USCG-014, Military Pay and Personnel System of Records, 76 Federal
Register 66933, October 28, 2011, and DHS/USCG-018, Exchange System and Morale Well-Being and Recreation System of Records, 73 Federal
Register 77736, December 19, 2008.
DISCLOSURE: Voluntary; however failing to provide the information may result in disqualification for the CGES Scholarship award.
Paperwork Reduction Act Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to
this information unless it displays a current valid OMB control number and an expiration date. The control number for this collection is OMB 1625-0119.
The estimated average time to complete this application is 60 minutes. If you have any comments regarding the burden estimate you can write to U.S.
Coast Guard, Community Services Command, 510 Independence Parkway, Suite 500, Chesapeake, VA 23320.

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