NAME:    _____________________________________________________

  ADDRESS: _____________________________________________________
           _____________________________________________________
            _____________________________________________________

   STATE OF PERMANENT RESIDENCY  ___________                             US CITIZENSHIP □   

 TELEPHONE:_____________________ 2ND TEL:_______________________
 E-MAIL:________________________ ID#_________________________

SCHOOLS ATTENDED  
HIGH SCHOOL           ADDRESS          COURSE               DATES          GPA
                                       OF STUDY __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

HIGHER EDUCATION
SCHOOL                ADDRESS         COURSE             DATES      DEGREES    GPA
                                      OF STUDY __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________

ACADEMIC PLANS FOR 2012-2013
Please list below the higher educational institution and degree program you anticipate attending during the 2012-2013 academic year. If you currently are applying to schools, please list these schools below. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________
__________________________________________________________________________________

1.Confidential letters of reference will be sent directly to the VSGC by:
          NAME                   TITLE                   ADDRESS 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________

The following information is optional, although essential for our national reporting. The VSGC
encourages full participation in its programs by women and members of minority groups.

     Male___ Female___ Minority Origin_____ Handicapped_____

       Are you a Vermont resident and United States citizen?   _____Yes    _____No

This application should be accompanied by an essay detailing your career plans and goals.  Please be as specific as possible, (NOT TO EXCEED 3 TYPED, DOUBLE-SPACED PAGES.

*Scholarships are not automatically renewable and awardees must complete all requirements when reapplying. THIS INCLUDES A DETAILED ESSAY stating your goals with relativity to NASA's interests.

The completed application form and essay should be mailed to the VSGC office:

Vermont Space Grant Consortium/NASA EPSoR
Votey Building
College of Engineering and Mathematics
University of Vermont
Burlington, VT 05405-0156
Telephone:(802) 656-1429,   Fax:(802) 656-1102 or 1104

*VSGC office is located in Pearl House, 12 Colchester Ave, (2nd floor) next to the UVM Mathematics Bldg

• Contact can also be made via direct email: zeno@cems.uvm.edu, or through the: VSGC html page: http://www.cems.uvm.edu/VSGC

You should also arrange for official transcripts of your academic record to be sent to VSGC at the above address. TO BE ELIGIBLE FOR THE 2012-2013  SCHOLARSHIP COMPETITION:
All application materials, including completed form, essay, transcripts, and three letters of reference, MUST BE RECEIVED NO LATER THAN APRIL 13, 2012