Graduate School Doctoral Dissertation Completion Grant Nomination Form
1/1/2016-6/30/2016
To nominate a graduate student for a Doctoral Dissertation Completion Grant, please complete this form
and attach the following supporting documentation:
-
A brief (one page) summary of the project, including research question(s), data or texts, and
method.
-
A justification of the need for the award from the student’s committee chair. This should include
the student’s 1) research progress to date, 2) the type of obstacles or difficulties being
encountered that are hindering the completion of the dissertation, 3) how these difficulties have
prevented the nominee from making satisfactory progress on the dissertation, and 4) the extent to
which the student has potential to complete the dissertation within the grant period. (It is important
to address not only financial obstacles, but other obstacles as well. Nominations that identify
obstacles beyond those that are financial will receive highest priority.)
-
Statement of interest and justification for participation in this program from the nominee.
-
A one-page proposal outlining a plan (including a time-line) for completion of the dissertation.
-
A CV for the nominee.
This form and supporting documentation should be compiled into a single pdf document and e-mailed to
Dr. David Shafer, Assistant Dean of the Graduate School (david_shafer@ncsu.edu). The deadline to
receive nominations for the January 1, 2016 – June 30, 2016 grant period is October 15, 2015.
1.
Personal Data
Name of Nominee:
___________________________________________________________
Last
First
Middle
Student ID Number: ______________________________
Mailing Address: _____________________________________________________________
Street/Box
______________________________________________________________
City/Town
State
Home Telephone:
E-Mail Address:
Office Phone:
_____________________
Department and/or graduate program:
Committee Chair:
Zip
Cell Phone:
________________________
___________________________________________
_______________________________________________________
Committee Chair’s E-Mail Address: ___________________________________________
Committee Chair's Mailing Address: ______________________________________________
Street/Box
______________________________________________________________
City/Town
State
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Zip
Graduate School Doctoral Dissertation Completion Grant Nomination Form
1/1/2016-6/30/2016
Present Status:

U.S. Citizen
 Permanent Resident of USA
Gender:

Female
 Male
Ethnicity (optional):
African AmericanAlaskan Native/Pacific Islander
 American Indian

2.
 Asian
Hispanic
 White
Education
Name of School/
Location
Attendance
From
To
Degree Received
Degree
Major
Date
Graduate Cumulative GPA:
3.
Statement of Nomination
I,
, hereby nominate
(Committee Chair)
for a
(Nominee)
Doctoral Dissertation Completion Grant.
I certify that the nominee:
A.
B.
Has met all course requirements and passed preliminary written and oral exams;
Will complete all research and analysis for the dissertation by January 1, 2016 and that all that
remains to complete it is the writing of the dissertation.
Signed
Date ___________________
Committee Chair
Signed
Date ____________________
Department Head or Director of Graduate Programs
(Appropriate authorizing official should sign)
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Graduate School Doctoral Dissertation Completion Grant Nomination Form
1/1/2016-6/30/2016
4.
Statement from Nominee
A. I understand that I must have completed all research and analysis for my dissertation prior to
the grant start date and that all that will remain as of January 1, 2016 is the writing of the
dissertation. (Grant offers may be withdrawn if research and analyses are not complete by the
grant start date.)
B. I will not hold a TA or RA or outside employment during the grant period indicated above.
C. I will register full time during the period of the grant.
D. In accepting this grant, in addition to the requirements of my graduate program, I will
participate in the following activities:
1. Attend support group meetings and writing workshop with other awardees;
2. Meet regularly with a designated dissertation writing coach;
3. Actively support other grantees in meeting the shared goal of completing
their dissertations; and
4. Dedicate the 6-month grant period to finishing the dissertation.
E. I understand that the Grant will provide a 6-month stipend in the amount of $10,000, as well as
tuition and health insurance.
Signed
Date ___________________
Nominee
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