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                                           Pellissippi State Technical Community College 
                                                 NATIONAL SCIENCE FOUNDATION 
COMPUTER SCIENCE, ENGINEERING and MATHEMATICS SCHOLARSHIP APPLICATION
Complete all *required information before submitting form.
Completion of other items is requested; this information is used for NSF reporting purposes only.
All materials must be postmarked by March 15 for priority consideration.
Applications received after March 15 will be considered only if funds are still available.
       *Last Name..................................................   .           .     .......*First Name....        . . .........            .....*MI 
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     *Permanent Address (number and street)............................ ..  .     . ....*City ............  .      .  ......*State..    .. *Zip Code 
  .    .   .
  *Telephone Number.  .         ..*SS Number.              ..Date of Birth......                      .....E-mail Address             .....
.   .
..... .....  .....*Citizenship .....................  ........  ......Ethnicity/Race.................              ...............Gender.... 
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.....  .....Disability Status...............         .    .         ......rOther Disability....................        ..........*Student Status..
. . 
Other Colleges Attended..
*Select [only one] intended Pellissippi State Major      
Transfer Majors     
(Two years at PSTCC plus two years at a University)     
.. .

Career/Technical Majors     
(Two years at PSTCC only)     

 
+These majors have been discontinued.  Students already enrolled in these programs may complete their degrees.
I hereby authorize the Financial Aid Office at Pellissippi State to release any information in my permanent student
records and financial aid records to the individual(s) responsible for the screening and/or selection of the NSF CSEMS
scholarships.  I understand that all information will be held in complete confidence.
I certify that the information in this application is true and hereby agree that in the event I receive an NSF CSEMS, my
grade point average, address, stated goals in life, and other pertinent information can be released to the NSF, the
Pellissippi Foundation's board of trustrees, and in publicity regarding NSF and Foundation activities.  I also agree to
cooperate with Pellissippi State in tracking my future academic progress and career decisions in order to conduct 
required follow-up studies regarding NSF CSEMS recipients.
..............        ..*Signature..................... ......      .................... .............*Today's Date ............................
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......Print a copy of this page for your records before you submit your application. 
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                                      Questions or problems with this page? ... E-mail:   jahrens@pstcc.edu
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