Diversity Support Program
Nomination Application Form
Purpose
Graduate Education actively engages in programs that support diversity and excellence at Arizona State University by contributing to
the recruitment, retention and degree completion of graduate students. Below are two initiatives Graduate Education supports to ensure
stellar underrepresented graduate students are supported in their academic endeavors, financially and academically. Graduate
Education Fellowships are awarded on the basis of nominations from the Academic Unit only.
Procedure
Application must be completed and submitted by the admitting academic unit to Jennifer Cason. Email: Jennifer.Cason@asu.edu,
fax: 480-727-6615, or bring to: Interdisciplinary B (formerly ADMB), Suite 285.
Nominee Information
LAST, FIRST, MIDDLE NAME:
ASU AFFILIATE/EMPLOYEE ID#:
Nominee ASU Academic Information (the student will be NEW to this program)
COLLEGE:
DEGREE:
PROGRAM:
Masters
PhD
THIS NOMINEE HAS THE FOLLOWING ON FILE IN WEBEXTENDER
Personal Statement/Statement of Purpose
Letter of Intent
Nominee Alumni Institution Information
UNDERGRADUTE ALUMNI INSTITUTION:
UNDERGRADUATE GPA:
GRADUTE ALUMNI INSTITUTION IF APPLICABLE:
GRADUATE GPA:
PREVIOUS SCHOLARSHIP PROGRAMS:
McNair
GRE SCORES:
Gates
MARC
Verbal Reasoning
Other
Quantitative Reasoning
Analytical Writing
GMAT SCORES:
LSAT SCORES:
Fellowship
Doctoral Enrichment Fellowship
Reach for the Stars Fellowship (masters students only)
If you are submitting more than one nominee, please rank this nominee in comparison to all your nominees.
(i.e. 1 of 3 )
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Please Complete
NOTE: Nominees must be worthy of ASU recognition and have both a diverse and academic history that support authenticity and
excellence. This should include the nominee’s strengths and scholarly promise, the nominee’s capacity to contribute to the
diversity of the graduate student community and to their discipline. (This may include individual circumstances of an exceptional
nature; cultural or socioeconomic background; unique experiences such as studies abroad, multiculturalism, and bilingualism; extent of
work or activities while in college; gender or race/ethnicity; and character of work or other non-academic experiences including
community service, in addition to such traditional indicators as grade point average, test scores, publications, conference presentations,
and academic honor). For more information visit ASU’s Diversity Plan: Building Blocks for Success from the University Provost
Please provide a written evaluation which describes this nominee’s contribution to diversity in the particular field of study and explain
why this nominee deserves ASU recognition.
Describes the components within your academic unit that will support the GC Diversity Support Program fellowship initiative of A.)
mentorship, B.) professional development and C.) interdisciplinary studies.
Providing the student makes satisfactory progress, does the Academic Unit commit financially to supporting the student the
following academic year with at least a 50% TA/RA or similar funding for two consecutive semesters?
Yes
No
Please describe frequency of the faculty mentor and fellow interaction.
Daily
Weekly
Bi-weekly
Monthly
What other funds are being used to recruit this student (i.e. recruitment airfare award, department funds, block grant funds,
TA/RA position) ?
Funding source
Amount $
Funding source
Amount $
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Department Approvals
(If you are submitting this nomination electronically, signatures are not required. However, all parties must be copied in the email
submission.)
Faculty Mentor/Advisor
NAME
EMAIL ADDRESS
SIGNATURE
PHONE
DATE
Graduate Director
NAME
EMAIL ADDRESS
SIGNATURE
PHONE
DATE
Chair of Academic Unit
NAME
EMAIL ADDRESS
SIGNATURE
PHONE
DATE
Business Office Manager
NAME
EMAIL ADDRESS
PHONE
EMAIL ADDRESS
PHONE
Graduate Support Staff
NAME
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Graduate Education Committee Approval
APPROVED
DENIED
DATE
Arizona State University does not discriminate on the basis of race, color, national origin, sex, sexual orientation, gender identity, disability, religion,
age or veteran status in the University’s services, educational programs, and activities, including, but not limited to, admission to and employment by the
University. The Office of Equity and Inclusion has been designated to handle inquiries regarding the University’s non-discrimination policies: Executive
Director, Office of Equity and Inclusion, University Services Building, 1551 S. Rural Rd., Tempe, Arizona 85287, Intercampus Mail Code 5612 Phone:
(480) 965-5057. For information about ASU’s non-discrimination policies and procedures for filing complaints, please see
https://provost.asu.edu/index.php?q=policies/procedures/p20.html.
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