Jack Pope Fellows Program
2015-2016
Nomination and Supporting Information
Affirmation of Candidacy and
Authorization for Release of Information
I, _________________________________, understand that I am applying for a Jack Pope Fellows Program and
affirm my wish to be considered. Permission is hereby given to officials of the nominating committee to release
transcripts of my academic record to date and other requested information for consideration in the Jack Pope
Fellows Program.
Date___________________Signature_____________________________________________________
BIOGRAPHICAL QUESTIONNAIRE
Note: The selection of scholarship recipients will be influenced by the completeness of replies, neatness, and
legibility. Please type or print (in black ink) all information. Narrative sections on pages 3 and 4 must be
typed. Please return the completed form to Jack Pope Fellows Program, ACU Box 29143, Abilene, TX 79699.
Applications are due by 5:00 p.m. on March 3, 2015.
A. You - the Nominee
Legal name in full __________________________________________________________________
(please print)
last
first
middle
Preferred Name
Banner ID #_______________Telephone_______________
Legal residence________________________________________________________________________
Street and number
Date of Birth
City
Age
Mo. / Day /
State
Zip
SS#___________________________________________
Year
Are you a United States Citizen? Check one: Y____
N____
Check one:
Sex M
F ___
B. Education
List in chronological order all schools attended in the last four years, including any for summer or special courses.
If more than four months elapsed between high school and entry into college, please specifically state your activities
during that time. Also list any significant college work that is more than four years old.
Name of School
Location (City and State)
Dates Attended
What course of study (major) are you following in college?
(You may indicate more than one.)
When do you expect to receive your baccalaureate degree? Month
Year
Do you plan to go to graduate or professional school after college?
If yes, what is your degree objective?
For what area(s) of public service are you preparing?
C. Activities and Work Experiences
1. List activities in which you have participated in your school (such as publications, debating and
dramatics, music, art, student government, and clubs). Place an "X" in front of those activities you
consider most important.
College Activity
Dates Participated
Office or Position Held
Special Awards
High School Activity
Dates Participated
Office Held
Special Awards
2. List community activities in which you have participated without pay (such as candy striping, church
work, drug hot lines, and outreach programs). Place an "X" in front of those activities you consider most
important.
Name of Agency
Kind of Work
Dates Participated
2
3. List jobs (including summer employment) you have held in the past three or four years.
Employer
Job position and kind of
work
Approximate dates of
employment
Approximate number of
hours per week
D. Of the community or public service activities you listed in C1 or C2, which one has been the most
significant to you? Why? (Please type.)
E. Indicate in which area(s) of public policy you are considering making your career and specify how
your current academic program and your overall educational plans will assist you in achieving this goal.
Which of your experiences, academic or other, has motivated you toward such a career? (Please type)
3
Applicant’s Essay
The Jack Pope Fellows Program is designed to provide opportunities for outstanding students to prepare for careers
in public service. In 600 words or less, please discuss a public policy issue of your choice; include a factual
description and analysis of the issue, your opinions, and the reasons supporting these options. The issue may be in
an area in which you intend to specialize, but this is not required. Some examples of issue areas include education,
energy, foreign relations, the environment, health, transportation, and welfare.
Note: Please type your essay. Confine it to the front of this sheet and one additional sheet if necessary.
Return this to Jack Pope Fellows Program, ACU Box 29143, Abilene, TX 79699
\
Name of Applicant:
Title:
4
Jack Pope Fellows Program
Financial Disclosure
Name of Applicant
Banner ID _______________________
1. Have you filled out a financial aid application form at Abilene Christian University?
Yes
No
2. Are you currently receiving a scholarship/grant?
Yes
_ No
3. Are you currently receiving federal/state financial assistance (PELL, TEG, GSL, etc.)?
Yes
No
Please return to: Jack Pope Fellows Program
ACU Box 29143
Abilene, TX 79699
5
Jack Pope Fellows Program
Independent Evaluation of Applicant
Instructions: Parts A and B of the form should be completed by the applicant and Part C by an appropriate individual of the
applicant's choice who is (please check one most appropriate):
An individual who can discuss the applicant's potential for a career in government service.
A faculty member who is in the applicant's field of study.
Another individual who can attest to the applicant's potential.
Part A:
Name of Applicant ________________________________________________________________________
Last
First
Middle
Part B: Waiver - I hereby waive my right, as provided by the Family Educational Rights and Private Act of 1974, to review or
have access to the contents of this letter of recommendation.
Date:
Applicant's Signature ______________________________________
Part C:
The student named above is applying for a Jack Pope Fellowship for students preparing for a career in public service.
To assist in its selection of the applicants who will be designated Jack Pope Fellows, the Jack Pope Fellows Steering Committee
would like to have your evaluation of this applicant's personal characteristics, potential for government service, and motivation.
On what criteria do you base your judgments? How does the nominee meet your criteria? We urge you to be as specific and
candid as possible, citing any particular incidents that illustrate the applicant's maturity, initiative, and potential.
Your evaluation will become part of the applicant's confidential file, intended for use by the Jack Pope Fellows Steering
Committee.
Name_____________________________________________________________________________________
First
Middle
Last
Title_________________________________________________
Address_______________________________________________
Length of time you have known the applicant?
In what capacity?
(Please use additional sheets if necessary.
Please do not write on the back of this sheet. )
Please return by March 3, 2014 to:
Jack Pope Fellows Program
ACU Box 29143
Abilene, TX 79699
6
Jack Pope Fellows Program
Independent Evaluation of Applicant
Instructions: Parts A and B of the form should be completed by the applicant and Part C by an appropriate individual of the
applicant's choice who is (please check one most appropriate):
An individual who can discuss the applicant's potential for a career in government service.
A faculty member in the applicant's field of study.
Another individual who can attest to the applicant's potential.
Part A:
Name of Applicant _________________________________________________________________________
Last
First
Middle
Part B: Waiver - I hereby waive my right, as provided by the Family Educational Rights and Private Act of 1974, to review or
have access to the contents of this letter of recommendation.
Date:
Applicant's Signature _______________________________________
Part C:
The student named above is applying for a Jack Pope Fellowship for students preparing for a career in public service.
To assist in its selection of the applicants who will be designated Jack Pope Fellows, the Jack Pope Fellows Steering Committee
would like to have your evaluation of this applicant's personal characteristics, potential for government service, and motivation.
On what criteria do you base your judgments? How does the nominee meet your criteria? We urge you to be as specific and
candid as possible, citing any particular incidents that illustrate the applicant's maturity, initiative, and potential.
Your evaluation will become part of the applicant's confidential file, intended for use by the Jack Pope Fellows Steering
Committee.
Name_____________________________________________________________________________________
First
Middle
Last
Title_________________________________________________
Address___________________________________________________________________________________
Length of time you have known the applicant?
In what capacity?
(Please use additional sheets if necessary.
Please do not write on the back of this sheet. )
Please return by March 3, 2014 to:
Jack Pope Fellows Program
ACU Box 29143
Abilene, TX 79699
7
Jack Pope Fellows Program
Independent Evaluation of Applicant
Instructions: Parts A and B of the form should be completed by the applicant and Part C by an appropriate individual of the
applicant's choice who is (please check one most appropriate):
An individual who can discuss the applicant's potential for a career in government service.
A faculty member in the applicant's field of study.
Another individual who can attest to the applicant's potential.
Part A:
Name of Applicant _________________________________________________________________________
Last
First
Middle
Part B: Waiver - I hereby waive my right, as provided by the Family Educational Rights and Private Act of 1974, to review or
have access to the contents of this letter of recommendation.
Date:
Applicant's Signature _______________________________________
Part C:
The student named above is applying for a Jack Pope Fellowship for students preparing for a career in public service.
To assist in its selection of the applicants who will be designated Jack Pope Fellows, the Jack Pope Fellows Steering Committee
would like to have your evaluation of this applicant's personal characteristics, potential for government service, and motivation.
On what criteria do you base your judgments? How does the nominee meet your criteria? We urge you to be as specific and
candid as possible, citing any particular incidents that illustrate the applicant's maturity, initiative, and potential.
Your evaluation will become part of the applicant's confidential file, intended for use by the Jack Pope Fellows Steering
Committee.
Name_____________________________________________________________________________________
First
Middle
Last
Title_________________________________________________
Address___________________________________________________________________________________
Length of time you have known the applicant?
In what capacity?
(Please use additional sheets if necessary.
Please do not write on the back of this sheet. )
Please return by March 3, 2014 to:
Jack Pope Fellows Program
ACU Box 29143
Abilene, TX 79699
8