Fisk University

NSF/CSEMS Application(For new applicants)

Computer Science, Engineering and Mathematics Scholarship Program
(Dead line for application: Applications must be received within the first two weeks of
the Semester.)

Student’s Name: ____________________________________________________

Mr./Ms. Last First M.I.
Student ID: ______________________ DOB: __________________

Permanent Street: _____________________________________________

Address _____________________________________________
City: ______________________ State: ___ Zip: _________
Telephone: ________________ Cell phone: ______________
E-Mail: ___________________________________________

Local Street: _____________________________________________

Address _____________________________________________
City: _______________________ State: ___ Zip: _________
Telephone: ________________ Cell phone: _______________
E-Mail: ___________________________________________

Classification: ‫ ٱ‬Fr Major Subject: ________________________

‫ٱ‬So. Minor/Dual major Subject: _____________
‫ٱ‬Jr. Cumulative GPA: _____________________
‫ٱ‬Sr. GPA in Major: ________________________

Fisk Academic Advisor: __________________________________________________

For the current academic year, please indicate the amount of financial aid you expect to
receive from sources.

$ ____________ Scholarships and Fellowships

$ ____________ Loans
$ ____________ Research Assistantship

If any of the above have a work requirement, please indicate the total amount of hours
per week that you are required to work:

______________ hours/week

The following information is requested in order to help us meet our reporting

requirements to NSF
Educational Goal (check one) ‫ ٱ‬Bachelor’s ‫ ٱ‬Master’s
‫ ٱ‬2 Bachelor’s
nd
‫ ٱ‬Ph.D
‫ ٱ‬Other (Please specify)
___________________________________
Field of Study: ______________________

Career Goals ‫ٱ‬Higher Education ‫ٱ‬Non-NASA Federal Agency

‫ ٱ‬Faculty ‫ ٱ‬State/Local Government
‫ ٱ‬Administrative ‫ ٱ‬Non-Profit Organization
‫ ٱ‬Other (Please specify) ‫ ٱ‬Military
________________ ‫ ٱ‬Consulting
‫ ٱ‬Private Industry ‫ ٱ‬Other (Please specify)
‫ ٱ‬Teaching (K-12) ______________________________
‫ ٱ‬NASA

Demographics: ‫ ٱ‬African American ‫ ٱ‬Hispanic

‫ ٱ‬Native American ‫ ٱ‬Caucasian
‫ ٱ‬Pacific Islander ‫ ٱ‬All Other Students

Gender: ‫ ٱ‬Male ‫ ٱ‬Female

Citizenship Status: ‫ ٱ‬American citizen
‫ ٱ‬Permanent Resident
‫ ٱ‬Admitted as Refugees under Section 207 of the Immigration
and Nationality Act

Signature of the applicant:-------------------------------------------------Date:-----------------

Attach (1) a one-page letter describing your career and graduate school interest and explaining how the
NSF scholarship would help you to complete the degree.
(2) Certification that a declaration of major form has been filed
(3) Transcript
(4) two recommendation letters, at least one from a faculty who has taught you.

Return the completed form to:

Dr. Sanjukta Hota
Department of Mathematics
Fisk University
Dubois Hall- Room 208
1000 17th Avenue North, Nashville, TN 37208
or Fax to: 615-329-8634 Attention- Dr. S. Hota