UCI Graduate Division(To be completed by the student)Revision date: 10/25/2018
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Please reference for more information and specific instructions for file saving/naming conventions.
UCI Graduate Division(To be completed by the student)Revision date: 10/25/2018
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STUDENT INFORMATION / Instructions: Students interested in applying for the Public Impact fellowship should complete this form, save the completed copy (with all information included), print and sign it, and send the Microsoft Word file, a printed/signed copy of the form, and a current CV to their program’s graduate affairs staff member. The student’s faculty advisor and school Associate Dean must review the form, and the faculty advisor must providea letter of recommendation. Final nomination packets (including this form) must be submitted to the Graduate Division office by the school Associate Dean no later than 5pm on Friday, October 21, 2016.Student Name (Last, First, Middle):
Address:
City, State, ZIP: / Student ID #:
Student’s E-mail Address: / Student Phone: ()-
Dept./Academic Program: / Degree Objective: Ph.D.
Expected Date of Degree: / GPA: / Citizenship:
Faculty Advisor:
Educational and Career Objectives:
STUDENT PROFILE
Please provide a biographic Student Profile below of approximately 100 words. Include, where applicable, undergraduate university and previous degrees, research interests, current projects, honors, work experience, outside interests, and any special characteristics or activities.
STUDENT RESEARCH
Please provide a 300-400 word Student Research statement describing your research project, written for a committee of non-specialists in the field. The statement should highlight the positive public impact of the work and include progress to date and plans for completion.
Please note thatif you have applied for and accepted Financial Aid loans or Work-Study awards and subsequently receive any fellowships, the additional support may affect your eligibility for need-based financial aid. Please contact the Office of Financial Aid and Scholarships to determine if your eligibility will be affected. Please review the terms of any funding that you have accepted for AY 2016-2017 to ensure that you are eligible to receive additional fellowship funding before submitting your application. Please note that full $12,000 awardees may not be employed as ASEs during the award period.
REQUIRED SIGNATURE / Late or incomplete applications/nomination packets will not be considered. Students selected as finalists must be available to give a brief (5-minute) presentation on their research to the final selection committee in mid- to late-November.I understand that if I am awarded a Public Impact Fellowship, I give permission to the Graduate Division and the University to use my personal information and any photographs for purpose of promoting graduate education at UCI and/or informing the community as to the use of the Public Impact Fellowship as it pertains to me.I also agree to be available for and participate in presentations and discussions with legislators, donors, etc. regarding my research during winter and spring 2017.
Student Name / Signature / Date
UCI Graduate Division(To be completed by the student)Revision date: 10/25/2018
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