Johnson C. Smith University-McN-Application Form

Johnson C. Smith University McNair Scholars Program Application
McNair Scholars Program
University College and Student Success
Perry Hall, Room 304
Phone: 704.378.1194
Fax: 704.371.6626
Email: Mcnair@jcsu.edu

The Ronald E. McNair Scholars Program at Johnson C. Smith University is a federally-funded TRIO program, committed to providing first-generation, income-eligible, and underrepresented students, an enriching, rigorous educational experience. Through an array of comprehensive services and activities, including undergraduate research, faculty mentorship, workshops and seminars, and graduate school preparation, the program provides an engaging and supportive environment to prepare undergraduate students for doctoral studies.

The McNair Program is named in honor of Dr. Ronald E. McNair, one of seven crew members aboard the Space Shuttle Challenger. Despite social and economic barriers, Dr. McNair earned many outstanding achievements such as completing a Ph.D. in Physics from M.I.T. at the age of 26 and was the second African-American to fly in space. In addition, Dr. McNair received many distinguished awards, including the National Ford Foundation Fellowship and the Presidential Scholarship.

Please provide ALL of the following information to be considered for the JCSU McNair Scholars Program:
- Completed and signed online application
- Personal Statement (Upload)
- Two (2) Letters of Recommendation
- Copy of Federal Income Tax Return
- University/College Transcripts
PERSONAL INFORMATION
Name:*

First NameMiddle NameLast Name
Preferred Name
JCSU ID#:
Social Security #:
999-99-9999
Date of Birth:

MonthDayYear
mm-dd-yyyy
Gender:
Preferred Pronouns:
Race/Ethnicity: Please check all that apply):

American Indian/Alaskan NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Pacific IslanderWhiteOther
Citizenship

U.S. CitizenPermanent Resident *(If Permanent Resident, please upload copy of INS Documentation)
Permanent Resident Documentation Upload:

Cancelof
Marital Status

SingleMarriedDivorced
School Email Address:*
example@example.com
Personal Email Address:
example@example.com
Campus/Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates available at this address
Residence Phone
(999)999-9999
Cell Phone
(999)999-9999
Permanent Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dates available at this address
Permanent Home Phone Number
(999)999-9999
Cell Phone
(999)999-9999
Emergency Contact Information

(This is your next-of-kin or someone you feel comfortable making medical decisions on your behalf.)
Name

First NameMiddle NameLast Name
Relationship to you
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Home Phone
(999)999-9999
Cell Phone
(999)999-9999
Additional information, if necessary:
Please indicate how you were referred to the JCSU McNair Scholars Program:

Academic AdvisorMcNair staffMcNair scholarWeb siteOther
ELIGIBILITY

All of the following information is used to assess your eligibility based on federal regulations. Please check all appropriate categories and sign at the bottom of this form.
First-Generation

First-Generation Status: The U.S. Department of Education defines a first-generation college student as an individual who grew up in a household where neither biological/adoptive parent received a 4-year degree before the individual turned 18.

What is highest level of education attained by your parent?
Biological Mother/Adoptive Parent:
Biological Father/Adoptive Parent:
Briefly provide any additional information, if necessary, regarding your family/living situation (i.e.. homelessness, foster care, recent adoption, etc.):
Income Eligible

Income Eligibility: The U.S. Department of Education defines income eligibility as an individual whose family's taxable income did not exceed 150 percent of the poverty level in the calendar year preceding the year in which the individual participates in the McNair Program.
For financial purposes, are you considered an independent or dependent student:

DependentIndependent
Based on the information, please provide a copy of tax returns for yourself or your parents.

Cancelof
Tax Status (choose one):

Listed as dependent on parents’/legal guardian’s tax returnSingle (not listed as dependent on anyone’s tax return)Married, filing jointlyMarried, filing separatelyHead of household, with qualifying person(s)Widow(er) with dependent child or childrenParents and/or self did not pay taxes within the past 3 years
Please list the number of dependents you claim on your return (not including yourself):
dependents claimed
How many people, including yourself, are currently living in your household?
(Line 6d on Income Tax Forms 1040 and 1040A)
Family annual taxable income (for last tax year):
(Line 43 on Income Tax Form 1040, line 27 on Form 1040A, Line 6 on Form 1040EZ)
Underrepresented

The U.S. Department of Education considers the following ethic and racial groups underrepresented in graduate education: Black (non-Hispanic), Hispanic, American Indian, Alaskan Native, Native Hawaiians, and Native American Pacific Islanders.
Please check all that apply:

Black or African AmericanHispanicAmerican IndianAlaskan NativeNative HawaiiansNative American Pacific IslandersNot Applicable
Were you a previous TRIO participant?

NoYes
If you were a previous TRIO participant, please select the program:

Talent SearchUpward BoundStudent Support ServicesEducational Opportunity CenterMcNair (at another institution)Not Applicable
ACADEMIC INFORMATION
Major:
Minor:
Name of your academic advisor:

First NameLast Name
Number of credits earned to date:
Credits required to graduate:
Cumulative GPA (all courses):
GPA in Major(s):
Class standing:

First YearSecond YearThird YearFourth Year
Date of first college/university enrollment:

MonthDayYear
mm-dd-yyyy
After attaining your high school diploma/GED, did you ever attend a community college?

YesNo
Projected graduation date:

MonthDayYear
mm-dd-yyyy
Are you currently registered as a full-time undergraduate?

YesNo
Have you taken college courses at any other institutions?

YesNo
If yes, please list all additional colleges attended and dates of attendance:
Have you taken a Research Methods course in your major?
If not, do you plan to take a research methods course in the upcoming semester?
What is your projected date of entrance into graduate school?

MonthDayYear
mm-dd-yyyy
In what field do you wish to pursue a Ph.D. degree?
Please upload a copy of your most recent unofficial university transcript. If you transferred to Johnson C. Smith University, please also upload unofficial transcripts from your previous institution(s).

Cancelof
Faculty Mentor Information

Provide the names and departments of two JCSU faculty members who you believe would be ideal mentors for your research internship. (NOT REQUIRED - we will assist you in picking a faculty mentor.)
Mentor 1

First NameMiddle NameLast Name
Mentor Email
example@example.com
Mentor 2

First NameMiddle NameLast Name
Mentor Email
example@example.com
Have you discussed this project with either or both professors?
Letters of Recommendation

Two letters of recommendation are required for your application. These letters must come from faculty, preferably in your major. Please provide the names of two faculty members who can address your academic aptitude and potential for graduate education. Once your application is submitted, your recommenders will receive a link for the recommendation form. The recommendation form will include an assessment of your attributes and skills as well as a separate letter that should address the following:
- An explanation of how they know you
- Your potential for successful entry into graduate school and completion of a doctoral degree
- Your skills and strengths, as well as areas for improvement
- The ways in which the McNair Scholars Program may benefit you
Recommender's Name 1

First NameLast Name
Email
example@example.com
Recommender's Name 2

First NameLast Name
Email
example@example.com
My signature indicates that, to the best of my knowledge, the information given in this application is true, complete, and accurate.
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
Johnson C. Smith University

McNair Scholars Program

Signature Release Form/Certification
This release form enables the JCSU McNair Scholars Program to obtain the following information for the purpose of determining eligibility, developing education plans, and collecting program statistics:

• College/university admission & enrollment

• Grade reports/transcripts

• Financial aid reports and information regarding scholarships, fellowships, and other awards received

• U.S. residency status

• Current contact information (address, phone number, email address)

• Past TRIO participation

Aspects of this information and the nature of your participation in the McNair Scholars Program may be shared with the U.S. Department of Education, the McNair Program Advisory Board and JCSU personnel in accordance with federal regulations and JCSU policy.

My signature below indicates that I hereby authorize the release of my academic, personal, and medical (when necessary) records to the McNair Scholars Program at Johnson C. Smith University for the purpose of serving my needs and meeting its federal regulations. I also hereby attest that, to the best of my knowledge, the information given in this application is true, complete, and accurate.
Name

First NameLast Name
SS#
999-99-9999
JCSU ID#
Signature

Clear
Date

MonthDayYear
mm-dd-yyyy
PERSONAL STATEMENT

Personal Statement (300 - 500 words)

Please write a statement describing your educational and career goals from completion of your undergraduate degree through completion of your graduate/doctorate-level degree. Explain what you have done to prepare yourself to meet these goals (courses, work, extracurricular activities, etc.). In what ways would you like the McNair Program to help strengthen your preparedness for graduate school? What motivates you to pursue graduate studies?

Additionally, outline one or more research interests upon which you would like to focus during the internship or fellowship period. Your statement should include the following components:

• What is your definition of research? Why would you like to pursue a research project in this (or these) particular topic area(s)?

• What experience do you have with your research topic(s) of interest?

• Value of the research interests to you (e.g., how would research in these areas fit into your academic or career aims?)
LINK TO UPLOAD PERSONAL STATEMENT

Cancelof

Johnson C. Smith University McNair Scholars Program Application

PERSONAL INFORMATION

ELIGIBILITY

ACADEMIC INFORMATION