NEW STUDENT APPLICATION - George Mason University D NEW Student... · Official Transcript(s)...
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Page | 1 OMB Control Number : 0704-0486 OMB Expiration Date: DoD Cyber Scholarship Program NEW STUDENT APPLICATION PRIVACY ACT STATEMENT: Authority for collecting information requested on the DoD Cyber Scholarship Program Application is contained in 5 U.S.C. Section 4101‐4121, 10 U.S.C. §2200, Executive Order 13111, Executive Order 11348, as amended, and DoD Directive 8500.2. DoD’s Blanket Routine Uses (found at Appendix C of 32 CFR Part 310) and the specific uses found in GNSA27 apply to this information. The requested information will be used to determine eligibility for the Cyber Scholarship Program. Disclosure of the requested information is voluntary. However, failure to provide the requested information will prevent the processing of your application and the determination of your eligibility for the Cyber Scholarship Program. AGENCY DISCLOSURE NOTICE: The public reporting burden for this collection of information is estimated to average 6 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center Drive, East Tower, Suite 03F09, Alexandria, VA 22350‐3100, [OMB Control Number (0704‐0486)]. Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. PLEASE DO NOT RETURN YOUR APPLICATION TO THE ABOVE ADDRESS. APPLICATIONS SHOULD BE SUBMITTED TO YOUR UNIVERSITY POINT OF CONTACT.
Transcript of NEW STUDENT APPLICATION - George Mason University D NEW Student... · Official Transcript(s)...
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OMB Control Number : 0704-0486 OMB Expiration Date:
DoDCyberScholarshipProgram
NEW STUDENT APPLICATIONPRIVACYACTSTATEMENT:
AuthorityforcollectinginformationrequestedontheDoDCyberScholarshipProgramApplicationiscontainedin5U.S.C.Section4101‐4121,10U.S.C.§2200,ExecutiveOrder13111,ExecutiveOrder11348,asamended,andDoDDirective8500.2.DoD’sBlanketRoutineUses(foundatAppendixCof32CFRPart310)andthespecificusesfoundinGNSA27applytothisinformation.TherequestedinformationwillbeusedtodetermineeligibilityfortheCyberScholarshipProgram.Disclosureoftherequestedinformationisvoluntary.However,failuretoprovidetherequestedinformationwillpreventtheprocessingofyourapplicationandthedeterminationofyoureligibilityfortheCyberScholarshipProgram.
AGENCYDISCLOSURENOTICE:
Thepublicreportingburdenforthiscollectionofinformationisestimatedtoaverage6hoursperresponse,includingthetimeforreviewinginstructions,searchingexistingdatasources,gatheringandmaintainingthedataneeded,andcompletingandreviewingthecollectionofinformation.Sendcommentsregardingthisburdenestimateoranyotheraspectofthiscollectionofinformation,includingsuggestionsforreducingtheburden,totheDepartmentofDefense,WashingtonHeadquartersServices,ExecutiveServicesDirectorate,DirectivesDivision,4800MarkCenterDrive,EastTower,Suite03F09,Alexandria,VA22350‐3100,[OMBControlNumber(0704‐0486)].Respondentsshouldbeawarethatnotwithstandinganyotherprovisionoflaw,nopersonshallbesubjecttoanypenaltyforfailingtocomplywithacollectionofinformationifitdoesnotdisplayacurrentlyvalidOMBcontrolnumber.
PLEASEDONOTRETURNYOURAPPLICATIONTOTHEABOVEADDRESS.APPLICATIONSSHOULDBESUBMITTEDTOYOURUNIVERSITYPOINTOFCONTACT.
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I.THISCHECKLISTISREQUIREDTOBETHEFIRSTPAGEOFTHEAPPLICANTPACKAGE,ANDMUSTBESIGNEDBYTHESTUDENTAPPLICANTANDTHEPI.
StudentName:
CurrentAddress: SecondAddress:
PhoneNumber(cell)
PhoneNumber(LandlineorPermanent):
StudentSchoolEmailAddress:
AlternateEmailAddress(gmail/yahoo/hotmail,etc….)
ALLCySPAPPLICANTSMUSTANSWERALLQUESTIONS
ACTIVITY/QUESTION ITEM INCLUDED / ANSWER (Y/N)
STUDENT
INITIALS
P.I. INITIALS
CURRENT U.S. Citizen:
Official Transcript(s) Provided:
Cumulative GPA – provide score in next column GPA MUST match transcripts. (No Rounding)
Currently enrolled or accepted for enrollment, at a CAE:
For which degree level are you requesting consideration by the DoD CySP? This may or may not be
your current degree program. You may have a dual program (Undergrad/Grad, Masters/PhD)
Single Dual
Bachelor’s
Master’s
PhD/Doctorate
ANTICIPATED FINAL GRADUATION DATE OF THE DEGREE PROGRAM ABOVE
Month /Year
/20
RESUME – Package will be deemed incomplete without
one attached
Awards, Honors and Distinctions list attached
2 Letters of Reference:
Last Name Only:
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VeteranStatus:
Ifyestoabove,indicatewhether5or10yearstatus
Proofofeligibilityattached
OF612SupplementalInformationChart(SectionII)OF612SupplementalCompetencyStatement
SupplementalStatementofGeneralAcademicandEmploymentConditionsDepartmentofDefense(DoD)Agency Location Choices *(SeeSectionG,Paragraph10–Mayleaveblank)
AgencyLocationChoice#1
AgencyLocationChoice#2
AgencyLocationChoice#3
Iwouldbeinterestedinactivedutymilitary serviceas a meanstomeetingmyobligatedservicerequirements.(AnswerYesorNo)1
IamcurrentlyamemberoftheNationalGuardoraReserveUnit: ___Yes ___No
StudentSignature:
StudentPrintedName:
P.I.Signature:
P.I.PrintedName:
1 Includes full-time active duty Guard and Reserves
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II. SupplementalInformation(Chart)A. ApplicantsfortheCySPmustprovidecertaininformationabouttheiracademicstandingtoenableareviewof
academicsufficiencybytheappropriateNationalCentersofAcademicExcellenceinCybersecurity,hereinafterreferredtoasCAEs.Thissectioncontainstherequiredsupplementalinformationrequirements.YouMUSTprovideALLrequiredinformationbelowtoreceivefullconsideration.Tobedeemedcompleteyoumustobtainandattachcertainadditionalmaterialstothisstatement.AllinformationandmaterialthatyouattachtothisstatementshallbecomepartofyourApplicationforFederalEmployment.
B. Providecompleteresponsestoallinformationrequirements,asapplicabletoyou,andattachtheadditionaldocumentsrequired.Signanddatethisstatementintheareaprovided.
BeginningintheFALLofAcademicYear2020-2021,Iwillenterthefollowing:
DeclaredMajorforthedegreelevel/programyouarerequestingconsiderationbytheDoDCySPis:
Numberofcreditsearnedtodateforthisdegree:______________________________________________________________
Numberofcreditsrequiredforgraduationforthisdegree:__________________________________________________
C. IhavelistedallcollegesoruniversitiesIhaveattendedinSection2belowandhaveprovidedthenecessaryofficialtranscripts.Donotincludethedegreeprogramlistedabove.(ifnecessary,provideadditionalinstitutioninformationonaseparatesheetattachedtothisform).
Institution State Dates Attended Degree Earned GPA
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Recognitions‐Honors‐Awards
Separatesheethighlightingrecognitions,honorsandawards: Attachaplain8½”X11”paperwithyournameandschool.Describeanyacademicrecognition(certificationsincluded),honors,distinctions,orawardsthatyouhavereceived.Thisisveryimportant,asitcountstowardstheevaluationcriteria.
NOTE
Therecognition,honors,distinctions,orawardsthatyoudescribeinthissupplementalstatementneednotbejob‐related.
Be sure that you include any scholarships, membership in any honorary societies to which you wereadmittedbecause ofacademicaccomplishment, andany significant leadership roles in academicgroups,organizations,societies,orassociationstowhichyouwerenominatedorelected.
Provide sufficient summary information for evaluators to understand the period or date of theaccomplishment,theawardinginstitutionororganization,andwhatyoudidtoearntherecognition.
DONOTATTACH:a. CopiesofDegreesb. CopiesofCertificatesc. CommemorativeMemorabiliad. Compositionse. Publicationsf. PersonallyIdentifiableMedia(Driver’sLicense,SocialSecurityCards,MilitaryIDs,etc.)
D. Youmustattachtwo(2)LettersofReferencetothissupplementalstatementfrompersonsknowledgeableofyourpotentialforsuccessfullearning,aswellasyourknowledgeandability.Atleastoneoftheselettersmustbefromacurrentfacultymember[oramostcurrentfacultymember],andthesecondlettermaybefromeitheracurrentorformerfacultymember,oracurrentorformeremployer.Eachlettermustcontainthename,positionortitle,telephonenumber,emailaddress,andinstitutionalororganizationaladdressofthereferee.Inaddition,youmustrequestthateachrefereerefertoandaddressthefollowingfactors:
a. The relationship of the referee to you. (The referee states whether the information is based on an academicor employment relationship.)
b. The length of the relationship. (The referee states how long he or she has known you.)c. An assessment of your potential for academic success and fulfillment of degree requirements. (Advise your
referees that your college or university will base a determination of your academic sufficiency, in part, onthe letters of reference that you submit.)
d. Anassessmentofyourknowledgeandabilityfollowingthesix(6)competencyareaslistedinSectionFbelow.
E. Bysigningthissupplementalstatement,Iacknowledgethattheinformationgivenaboveistrueandcorrect:
NAME:_________________________________________________________________________________________
SIGNATURE:___________________________________________________________________Date:_____________________________
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F. COMPETENCYSTATEMENT (OF612‐APPLICATIONFORFEDERALEMPLOYMENTSUPPLEMENTAL)
Onplain8½”x11”paper,titleasabove,describeyourknowledgeandabilityineachofthesix(6)competencyareasbelow.Theevaluationpointsareveryhighinthisarea.Youmustaddresseachareaidentified.Ifyoudonotprovidethisinformation,yourpackagewillbedeemednon‐responsiveandwillnotbeconsidered.
Indicateyournameandschoolnameoneachpage. Limityourresponsesonallsixcompetencyareastoatotalofthreepages.
a. Knowledgeofthetechniquesofthecybersecuritydiscipline,includingencryption,accesscontrol,physicalsecurity,training,threatanalysis,andauthentication.
b. Knowledgeofthehumanfactorsincybersecurity,includinghumancomputerinteraction,design,training,sabotage,humanerrorpreventionandidentification,personalusepolicies,andmonitoring.
c. Abilitytoidentifyandanalyzeproblems,distinguishbetweenrelevantandirrelevantinformationtomakelogicaldecisions,andprovidesolutionstoindividualandorganizationalproblems.
d. Abilitytoconsiderandrespondappropriatelytotheneeds,feelings,andcapabilitiesofdifferentpeopleindifferentsituations;istactful,compassionateandsensitive,andtreatsotherswithrespect.
e. Abilitytomakeclearandconvincingoralpresentationstoindividualsorgroups;listenseffectivelyandclarifiesinformationasneeded;facilitatesanopenexchangeofideasandfostersanatmosphereofopencommunication.
f. Abilitytoexpressfactsandideasinwritinginclear,convincingandorganizedmannersappropriatetotheaudienceandoccasion.
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F. OF612:
OPTIONALAPPLICATIONFORFEDERALEMPLOYMENTSUPPLEMENTALSTATEMENTOFGENERALACADEMIC
ANDEMPLOYMENTCONDITIONS
TobeconsideredfortheCyberScholarshipProgram(CySP),youmustagreetocertain academic standards andconditions of employment.This OF612 supplement describesthose conditions.Read this statement carefully,and indicate your elections,where appropriate.When you understandalloftheconditionscompletely,andagreewithallofthem,signanddatethestatement,andincludeitwithyourResumeandOF612Supplementalinformation.
1) Inordertoreceivefinancialassistance(ascholarship)orappointmentundertheDoDCyber Scholarship Program, youmust be enrolled (or accepted for enrollment)at one ofthe institutionsofhighereducation designatedbytheNationalCentersofAcademicExcellenceinCybersecurity (CAE-C), orenrolled (oracceptedforenrollment)inaninstitutionselectedbyaCAE-CasacollaboratingpartnerintheCyber ScholarshipProgram.
2) In order to receive financial assistance (a scholarship) or appointment under the CySP,the CAE-Catwhichyouareenrolled(oraccepted forenrollment)mustsubmitasuccessfulgrantproposal totheDoDtoestablishtheCySPontheircampus.
3) Inordertoreceive financialassistance(ascholarship)orappointmentundertheCySP,youmustbeenrolled(oracceptedforenrollment)inafull‐timeprogram1 leadingtoanundergraduateormaster’sdegree, ordoctoraldegree,andpursuingacourseofstudyand/orhaveadeclaredmajor in oneof the scientific, technical ormanagerial disciplines related to computer andnetworksecurity,witha concentration in a cybersecurityfunction.(In accordancewith 5CFR213.3202(b)(2),anindividualwhoneeds to complete less than theequivalent of half an academic course load in theclass enrollmentperiod immediately prior to graduating isstill considered a student forpurposesofthisprogram.)a) Cybersecurityencompassesthescientific,technical,andmanagementdisciplinesrequiredtoensure
computerandnetworksecurity,includingthefollowingfunctions: System/networkadministrationandoperations Systemssecurityengineering Informationassurancesystemsandproductacquisition Cryptography Threatandvulnerabilityassessment,toincluderiskmanagement Websecurity Operationsofcomputeremergencyresponseteams Computerforensics Defensiveinformationoperations Criticalinformationinfrastructureassurance
b) Relevantcyber‐relatedacademicdisciplines,withconcentrationsincybersecurity,wouldinclude,butarenotlimitedto:
Biometrics Business:
a. Management
1 If a student is applying for only one half of a school year (or graduates 1 semester early), that student shall only receive a pro-rated stipend. The stipend is based upon an annual full-time attendance at the University.
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b. Administration Computer:
a. CrimeInvestigationsb. Engineeringc. Forensicsd. InformationSciencee. InformationSystemsf. Programmingg. Scienceh. SystemsAnalysis
CriticalInformationInfrastructureAssurance Cyber:
a. Defenseb. Operationsc. Securityd. Policy
Cryptography DatabaseAdministration DataManagement DataScience DigitalandMultimediaForensics ElectricalEngineering ElectronicsEngineering InformationAssurance SystemsandProductAcquisition InformationSecurity(Assurance) InformationSystems InformationTechnology:
a. Acquisitionb. Program/ProjectManagement
Mathematics NetworkAdministrationandOperations NetworkManagement OperationofComputerEmergencyResponseTeams SoftwareEngineering SystemsSecurityEngineering ThreatandVulnerabilityAssessment,toincludeRiskManagement WebSecurity AnyothersimilardisciplinesasapprovedbytheDoDChiefInformationOffice(DoDCIO).
4) Ifyouareanundergraduatestudent,youmustmaintainanoverall3.2outofa4.0gradepointaverage(orananalogousrankbasedonacomparablescale)inordertoreceivefinancialassistance(ascholarship)undertheCySP.Ifyouareagraduatestudent,youmustmaintainanoverall3.5outofa4.0 (or an analogous rank basedon a comparable scale) in order to receive financial assistance (ascholarship).FailuretomaintaintheseminimumgradepointaveragesconstitutesgroundsforimmediateterminationoffinancialassistanceandyourappointmentundertheCySP.Additionally,ifyou fail to complete the degree program satisfactorilyortofulfilltheservicecommitmentupongraduation,youshallberequiredtoreimbursetheUnitedStates,inwholeorinpart,thecostofthefinancial(scholarship)assistanceprovided.
5) Except for small achievement awards (not to exceed $5,500 in any academic year), you may notacceptsimultaneous remuneration fromanother scholarshipor fellowshipwhile receiving financialassistanceunder
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theCySP.Ifyouareinagraduateprogram,youmayreceiveareasonableamountofremunerationforteachingorsimilaractivitiesasare,intheinstitution’sopinion,contributorytoyouracademicprogress.Exceptwherestate or local law, court orproper administrativeorderdeclaresotherwise,theDoDshallassumethatthedevelopmentofstudents,notservicetotheacademicinstitution,willgoverntheassignmentoftheseactivities.
6) Inorder to receive financial assistance (a scholarship)under theCySP, youmust agree to accepta federalappointment under the authority to employ individuals completingDepartment ofDefense ScholarshiporFellowshipProgram,oranotherhiringauthority. Youmaybeappointedunder thisprogramasaGS‐7,GS‐9,orGS‐11basedonyourqualifications,andtheneedsandconditionsoftheappointingdefensecomponent.Duringyourperiodofserviceunderthisappointment,iftimingpermits,youmustacceptandperforminternassignmentsdesignedtoenhanceyouracademicstudiesin cybersecurity.These assignmentswill be scheduledat timesmutually agreeable to you, yourschool,andtheDoDcomponentthatappointsyou.
7) Inordertoreceivefinancialassistance(ascholarship)undertheCySP,youmustagreetoworkfortheDoD,aftertheawardofyourdegree,asacivilian*employeeforonecalendaryearforeachacademicyear,orpartialyear,forwhichfinancialassistance(scholarship)isreceived.*Seeparagraph8 for termsofmilitaryservice, shouldyoudesire thisoption.This requirement is called“obligated service”. The work you may perform during aninternship DOES NOT COUNT towardsatisfactionofyourobligatedservicerequirement.
8) Should you desire to enlist or accept a commission to serve on active duty in one of theMilitaryServices2,youmustincuraserviceobligationofaminimumof4yearsonactivedutyinthatServiceupongraduation.TheMilitaryServicesmayestablishaserviceobligationlongerthan4years,dependingontheoccupationalspecialtyandtypeofenlistmentorcommissioningprogramselected..“Ifyouareinterestedinmilitaryserviceasameanstomeetingyourobligatedservicerequirements,pleaseindicatethisinSection10ofthisapplication.
9) In order to receive financial assistance (a scholarship) or appointment under the CySP, you mustagreetobemobile.Uponappointment,youwillberequiredtosignanagreementtoacceptassignments thatinvolve travelorchanges induty stations,assignments indifferentorganizations,assignmentsindifferentfunctionalareas,andassignmentsindifferentgeographicareas,duringyourinternship,ifapplicable,ANDduringyourincumbencyofanypermanent,full‐timepositiontowhichyouareconvertedonprogramcompletion.Your travel under this agreement, and the travelofallDoDcivilian employees, is governed by the FederalTravel Regulations and the DoD Joint TravelRegulations.Theseregulationsprovidefortravelbenefits,andpayorreimbursementofyourtravelexpenses,onanincidental,case‐by‐casebasis;it isnotpossibletospecifyyourexactentitlementtotravelbenefitsatthistime.
10) TheDoDdoesnotguaranteethatyourpreferences foragencyassignment(or location)undertheCySP, or ina permanent position towhich you are subsequently converted, canbe honored.Your preferenceswillbetakenintoaccount,alongwithallotherrelevantfactorssuchas:mission,functional, and staffing requirements;the exigencies of service; the availability of funds;and, any hardshipsyoumaydemonstrate. Nonetheless,youragencypreferencesareimportanttothedepartment.Therefore,youmayspecifyuptothreeagencypreferencesbelow,ifyouwish.Youarenotrequiredtocompletethesepreferenceselections.Youmayspecifycityandstateofpreference,ifknownaswell.ForinformationonDoDAgencies,youmayviewthefollowingwebsitewhichcontainstheOfficeof theSecretaryofDefense,DefenseAgenciesandDoDFieldActivities,OrganizationandFunctionsGuidebook:
http://www.defense.gov/about/
11) In order to receive financial assistance (a scholarship) under the CySP, youmust agree toreimbursetheUnitedStatesshouldyouvoluntarilyterminateyouremploymentwiththeDoDbeforethe end ofyourperiodofobligatedservice. (Seealso item7above.) ShouldyouterminateyourappointmentundertheCySP,declineorrefusetohonoryourcommitmenttoacceptpermanentemployment,or,voluntarilyterminatepermanentemploymentbeforeyouhave fulfilledyourperiodofobligatedservice,youmustreimbursetheUnitedStates,inwholeorinpart,thecostofthe financial (scholarship) assistance provided to you.Anobligation toreimburse under thisconditionofemploymentisforallpurposesconsideredtobeadebtowedtotheUnitedStates.
12) In order to receive financial assistance (a scholarship) or an appointment under the CySP,youmustagree
2 Includes full-time active duty Guard and Reserves
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tosigncertain formsauthorizingabackground investigation topermittheappointingagencytomakeadeterminationastoyoursuitabilityforfederalemployment.
13) Youwillberequiredtoobtainandmaintaineligibilityforasecurityclearanceinordertoreceive financial(scholarship) assistance or an appointment under the CySP. You may berequiredtoundergocertaintests,includingdrugandpolygraphtests,toobtainandmaintainaclearance. BeforeyoumaybeawardedascholarshiporhiredbyDoD ,youwillbe requiredto completecertainformstoinitiatethesecurityclearanceprocess.Someoftheseformswillrequirethatyourevealextensiveinformationaboutyourbackground,suchaspotentially sensitive informationaboutyour financialcircumstancesandanyarrestsand/orconvictions foroffensesofanykind.Youmustagreetoalloftheseconditionsofemploymentandyoumustcompletetheseformsasaconditionoffinancialassistanceandappointment.
Current web pages from the Office of Personnel Management (OPM) provided below. This is provided for yourreview and consideration in determiningwhether youwill be eligible for asecurity clearance. Thismay not be allinclusive, however, it is highly recommended that youreview and understand the requirements prior to signing upto participate in theDoD CySP.http://www.opm.gov/investigations/background‐investigations/
By signing this OF612 Supplemental Statement of General Academic and Employment Conditions, I acknowledge that I have read, understand, and agree to all of its conditions, to include the Security Clearance Requirements:
Name:
Signature: Date:
