NOMINATION FORM:
WARREN – WOLFPACK CLUB SUPPLEMENTAL GRADUATE
FELLOWSHIP
Instructions for Nominating Fellows
To nominate students for a Warren-Wolfpack Club Graduate Fellowship, please complete this
nomination form and attach the following supporting documentation: (1) two letters of
recommendation, (2) a statement of purpose from the student, and (3) a copy of the nominee’s
transcripts. The letters of recommendation and/or statement of purpose should include any
activities or positions held that may demonstrate the nominee’s leadership abilities or potential.
Directors of Graduate Programs should e-mail completed nomination forms to the attention of Dr.
David Shafer, Assistant Dean for Outreach and Diversity in the Graduate School, at
david_shafer@ncsu.edu.
Please note that nominees must be deemed eligible to receive this award according to NCAA rules.
The Graduate School will contact the Director of Compliance in the NC State University Athletics
Department to confirm the nominee’s eligibility. If the nominee is deemed ineligible, we will inform
the nominator and will remove the nomination from consideration.
1.
Personal Data
Name of Applicant
Last
First
Middle
Student ID Number______________________
Present Address_______________________________________________________________
Street/Box
City/Town
State
Zip
Permanent Address_____________________________________________________________
Street/Box
City/Town
State
Zip
Home Telephone
Office Phone_________________________________
E-Mail Address ___________________________________
Graduate Program_________________________________
Name of Advisor__________________________________________________________
Advisor's E-Mail Address___________________________________________________
2.
Education
Name of School/Location
Attendance
From
To
Degree Received
Degree Major
Date
WARREN – WOLFPACK CLUB SUPPLEMENTAL GRADUATE
FELLOWSHIP
GRE Scores: Verbal________Quantitative________ Analytical/Writing________
GRE Percentiles: Verbal_______% Quantitative________% Analytical/Writing________%
Undergraduate Cumulative GPA________
Out of Possible_________
Graduate Cumulative GPA
Out of Possible_________
Graduate Credit Hours Taken
3.
Activities, Memberships, Honors, Awards
4.
Publications and Academic Presentations
5.
Varsity Sport Played and Description of Athletic Achievements
6
a.
When (month and year) did the nominee initially enroll at a collegiate
institution for the first time?
b.
c.
During which years did the nominee compete on his/her team?
During which years did the nominee receive athletics aid while a
student-athlete?
=================================================================================
=
a. Will this student receive a TA, RA, or Fellowship in addition to this award? (Yes or
No)
b. If so, will the type of support be in the form of a ___TA, ___RA, and/or ___Fellowship.
c. If applicable, please indicate the annual amount of funding this student will receive
from each of the sources indicated in item b.
Signed __________________________________________
Director of Graduate Programs or Department Head
(Appropriate Authorizing Official Should Sign)
Date_____________________