2015 – 2016 AFCEA Scholarship
Please return this application to
UTSA Department of Computer Science
FLN 4.01.10
One UTSA Circle
San Antonio, Texas 78249
Last name (please print)
First name
@
Student ID number
Male / Female
Mailing address Number/street
Middle name
(Circle one)
City
State
Zip
County
E-mail address
Name of high school
(
)
Home phone number
(
)
Cell phone number
Application for (circle one): (Graduate AFCEA Scholarship) (Undergraduate AFCEA Scholarship)
Are you a current UTSA Student?
Are you a Texas resident?
Are you a member of AFCEA?
❑ Yes ❑ No
❑ Yes ❑ No
Are you a U.S. Citizen?
❑ Yes ❑ No
❑ Yes ❑ No
Membership #: _____________________
Are you enrolled in ROTC and do not have a current ROTC scholarship?
❑ Yes ❑ No
Are you an active member of the armed services or an immediate family member of somebody who is?
Are you a veteran of the armed services?
❑ Yes ❑ No
❑ Yes ❑ No
Which service and dates served: ________________________
Are you the first in your immediate family (father, mother, brother, sister, aunt, uncle) to attend college? ❑ Yes ❑ No
If no, please indicate relationship of relative and level of education attained: some college ❑ college degree ❑
Do you have a disability? ❑ Yes ❑ No
If yes, please attach documentation of your disability (must be within three years)
Under the ADA, an individual with a disability is a person who has a physical or mental impairment that substantially limits one
or more major life activities; has a record of such impairment; or is regarded as having such impairment.
Are you fluent in a language other than English? ❑ Yes ❑ No If yes, what language(s)? __________________
NOTE: Please include with your application package 2 letters of recommendation.
Academics (to be filled out for Undergraduate Scholarship Applicants)
For Freshman applicants: High school grad point average (GPA): __________SAT Score _______ ACT Score _______
If you are a transfer student, name of college transferred from: ____________________ GPA ______
If you are a Computer Science Major, Semester Hours of CS Completed: __________ Computer Science GPA _________
If you are an Information Systems or Information Assurance Major,
Semester Hours of IS or IA Completed: ___________ IS or IA GPA __________
If you are not majoring in CS, IA, or IS, what is your major? ____________________________ GPA: ___________
Anticipated Graduation Date: _______
Number of scholarship semesters requested:
1
2
___________________________________________________________________________________________________
Academics (to be filled out for Graduate Scholarship Applicants)
Where did you obtain your undergraduate degree? ________________________________________________________
What major was your undergraduate degree in? _________________________________________________________
What was your cumulative undergraduate GPA? __________________ Comp Sci, IS, or IA GPA ______________
What program are you in? __________________________________________ Degree sought: (Circle one)? MS
Anticipated Graduation Date: _______
If you are a PhD student, what is your current graduate GPA? _________
PhD
Statement of Purpose and/or Essay question (see individual scholarship qualifications for essay requirements):
Attach to this application any required essay along with a narrative describing your background, career interests and
professional goals and statement of purpose for applying for this scholarship. Please include your name and college admission
I.D. number stated at the top of your attachments.
High School Activities: List all school activities in which you have participated in the last four years (i.e., student government,
athletics, clubs, etc.). List all academic honors, scholarships, fellowships and assistantships. Attach additional pages if
necessary. Activities Year (1, 2, 3, 4) Position Total months participated Avg. hours per week. Please include your name and
college admission I.D. number stated at the top of your attachments.
College Activities: List all clubs, organizations, student government, etc. If any activities involved leadership positions, please
indicate. List all academic honors, scholarships, fellowships and assistantships. Attach additional pages if necessary. From
month/year To month/year Description of activity Leadership position held. Please include your name and college admission
I.D. number stated at the top of your attachments.
Research Interests and Publications, if any: Attach additional pages if necessary. Please include your name and college
admission I.D. number stated at the top of your attachments.
Community and Volunteer Activities: List all non-paid community activities in which you have participated in the last four
years (i.e., charity groups, church, hospitals, etc.). Include any memberships in professional organizations. Attach additional
pages if necessary. Activity (e.g. soup kitchen) Year (1,2,3,4) Position Total months worked Avg. hours per month Comment:
Certification (must be signed by all applicants) Please include your name and college admission I.D. number stated at the top
of your attachments.
Resume: Please attach a resume if you are currently employed including your current position and hours per week working.
Applicant’s Signature
Date
I certify that the information on this application is correct and true to the best of my knowledge. I hereby give permission for
this information to be released to the donor or potential donors of any scholarship for which I may be eligible. I also give my
permission to release my information to the donor of any scholarship for which I am selected. I also understand that furnishing
false information may result in revocation of my financial aid or may result in disciplinary action pursuant to the UTSA Code of
Student Conduct.
Privacy Notice
With few exceptions, you are entitled to be informed about the information U.T. San Antonio collects about you. Under
Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review this information. Under
Section 559.004 of the Texas Government Code, you are entitled to have U.T. San Antonio correct information about you that
is held by us and that is incorrect, in accordance with the procedures set forth in the University of Texas System Business
Procedures Memorandum 32. The information that U.T. San Antonio collects will be retained and maintained as required by
Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of
information are kept for different periods of time.