Mossie J. Richmond, Jr. – Afak Haydar Memorial Scholarship for International Students
Graduate Application Form
Application deadline is 5:00 p.m., Friday, March 16, 2012.
PART I: DEMOGRAPHIC INFORMATION
Name: ________________________________________ Student ID Number: __________________
Country of Citizenship: _________________________________________ Visa Status: ___________
Local Address: _____________________________________________________________________
Telephone Number: ________________________________________________________________
E-mail Address: ____________________________________________________________________
Date Entered ASU: ________________ Expected Date of Completion: ________________________
Field of Study: _____________________________________________________________________
Semester Hours Completed: ____________________________ G.P.A.: _______________________
PART II: ACADEMIC ACHIEVEMENTS
List all academic honors that you have received including scholarships, Dean’s List, Chancellor’s List,
assistantships, and academic awards.
PART III: ACADEMIC ACTIVITIES
List all activities in which you have been involved at ASU that are related to your courses and major, and
professional goals.
PART IV: LEADERSHIP
List any leadership positions you have held.
PART V: TELL US ABOUT YOURSELF.
Be sure to include any activities in which you have participated at ASU, information about your research
and professional goals, and explain how your academic work here correlates with these goals.
YOUR APPLICATION WILL BE CONSIDERED COMPLETE WHEN THE FOLLOWING ARE RECEIVED:
1.
2.
3.
4.
Completed application form.
An official, up-to-date transcript from each school you have attended.
Two confidential rating forms (see attached) from two different faculty members in your major field.
One confidential letter of recommendation from someone who has not submitted a confidential rating
form for you. Letter does not have to be from a faculty member.
Application form and all supporting documents must be received in the
Vice Chancellor for Student Affairs office
(Administration Building, room 233) no later than
5:00 p.m. on Friday, March 16, 2012.
Applicants selected as finalists must participate in an interview with the scholarship committee.
CONFIDENTIAL RATING FORM
Mossie J. Richmond, Jr. – Afak Haydar Memorial Scholarship for International Students
Name of Applicant: _____________________________________________________________
To the Referrer:
The above applicant has applied for the Mossie J. Richmond, Jr. – Afak Haydar Memorial
Scholarship for International Students. The applicant has selected you as a person who is
qualified to rate his/her ability and personality. Your cooperation in completing this rating
form will assist the scholarship committee in appraising this applicant. Completed form
must be received in the Office of the Vice Chancellor for Student Affairs (ADMIN 233) by
5:00 p.m., Friday, March 16, 2012. Please deliver or mail this form to Student Affairs, ATTN:
Richmond-Haydar Scholarship, P.O. Box 189, State University, AR 72467. The information
you provide will be treated confidentially.
Mark the following statements to the left of each number. Ratings should indicate:
5
4
3
2
1
0
Strongly Agree
Agree
No Opinion
Disagree
Strongly Disagree
No Opportunity
to Observe
_____ 1.
Student’s academic performance is above average.
_____ 2.
Student demonstrates a commitment to his/her field of study.
_____ 3.
Student is a critical thinker.
_____ 4.
Student is dependable and assumes responsibility.
_____ 5.
Student exerts maximum effort; this is reflected in performance.
_____ 6.
Student displays a positive attitude.
_____ 7.
Student is creative.
_____ 8.
Student demonstrates proficiency in verbal and written communication.
_____ 9.
Student is cooperative and considerate.
_____ 10.
Student is an outstanding representative of ASU’s international student community.
Please make any additional comments which might be helpful to the selection committee
on the back of this sheet. Thank you for your assistance.
Date______________________
Signature____________________________________________________
Print Name and Title ________________________________________________________________________
CONFIDENTIAL RATING FORM
Mossie J. Richmond, Jr. – Afak Haydar Memorial Scholarship for International Students
Name of Applicant: _____________________________________________________________
To the Referrer:
The above applicant has applied for the Mossie J. Richmond, Jr. – Afak Haydar Memorial
Scholarship for International Students. The applicant has selected you as a person who is
qualified to rate his/her ability and personality. Your cooperation in completing this rating
form will assist the scholarship committee in appraising this applicant. Completed form
must be received in the Office of the Vice Chancellor for Student Affairs (ADMIN 233) by
5:00 p.m., Friday, March 16, 2012. Please deliver or mail this form to Student Affairs, ATTN:
Richmond-Haydar Scholarship, P.O. Box 189, State University, AR 72467. The information
you provide will be treated confidentially.
Mark the following statements to the left of each number. Ratings should indicate:
5
4
3
2
1
0
Strongly Agree
Agree
No Opinion
Disagree
Strongly Disagree
No Opportunity
to Observe
_____ 1.
Student’s academic performance is above average.
_____ 2.
Student demonstrates a commitment to his/her field of study.
_____ 3.
Student is a critical thinker.
_____ 4.
Student is dependable and assumes responsibility.
_____ 5.
Student exerts maximum effort; this is reflected in performance.
_____ 6.
Student displays a positive attitude.
_____ 7.
Student is creative.
_____ 8.
Student demonstrates proficiency in verbal and written communication.
_____ 9.
Student is cooperative and considerate.
_____ 10.
Student is an outstanding representative of ASU’s international student community.
Please make any additional comments which might be helpful to the selection committee on the back of this
sheet. Thank you for your assistance.
Date______________________
Signature____________________________________________________
Print Name and Title ________________________________________________________________________