Public Impact Fellowship
AY 2015-2016
Student Information Form
Submit Materials to:
Your program’s Associate Dean via
your faculty advisor or graduate
affairs staff member.
Please reference http://www.grad.uci.edu/funding/fellowships-awards/internal/public-impact.php for more information and specific
instructions for file saving/naming conventions.
STUDENT
INFORMATION
Instructions: Students interested in applying for the Public Impact fellowship should complete this form,
save the completed copy (with all information included), print and sign it, and send the Microsoft Word file, a
printed/signed copy of the form, and a current CV to their program’s graduate affairs staff member. The
student’s faculty advisor and school Associate Dean must review the form, and the faculty advisor must
provide a letter of recommendation. Final nomination packets (including this form) must be submitted to the
Graduate Division office by the school Associate Dean no later than 12:00 p.m. (noon) on Friday,
October 23, 2015.
Student Name (Last, First, Middle):
Address:
City, State, ZIP:
Student ID # :
Student’s E-mail Address:
Student Phone: (
Dept./Academic Program:
Degree Objective:
Expected Date of Degree:
GPA:
)
Ph.D.
Citizenship:
Faculty Advisor:
Educational and Career Objectives:
STUDENT PROFILE
Please provide a biographic Student Profile below of approximately 100 words. Include, where applicable, undergraduate university
and previous degrees, research interests, current projects, honors, work experience, outside interests, and any special characteristics
or activities.
STUDENT RESEARCH
Please provide a 300-400 word Student Research statement describing your research project, written for a committee of nonspecialists in the field. The statement should highlight the positive public impact of the work and include progress to date and plans for
completion.
Please note that if you have applied for and accepted Financial Aid loans or Work-Study awards and subsequently receive any
fellowships, the additional support may affect your eligibility for need-based financial aid. Please contact the Office of Financial Aid and
Scholarships to determine if your eligibility will be affected. Please review the terms of any funding that you have accepted for AY
2015-2016 to ensure that you are eligible to receive additional fellowship funding before submitting your application.
Late or incomplete applications/nomination packets will not be considered. Students selected as
finalists must be available to give a brief (5-minute) presentation on their research to the final
selection committee in mid- to late-November.
I understand that if I am awarded a Public Impact Fellowship, I give permission to the Graduate Division and the University to use my
personal information and any photographs for purpose of promoting graduate education at UCI and/or informing the community as to
the use of the Public Impact Fellowship as it pertains to me. I also agree to be available for and participate in presentations and
discussions with legislators, donors, etc. regarding my research during winter and spring 2016.
REQUIRED SIGNATURE
Student Name
UCI Graduate Division
Signature
(To be completed by the student)
Date
Revision date: 02/18/2016
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