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NEW STUDENT APPLICATION (Davenport University)

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Page|1
OMB Control Number : 0704-0486
OMB Expiration Date:
DoDCyberScholarshipProgram
NEW STUDENT APPLICATION
PRIVACYACTSTATEMENT:
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.
AGENCYDISCLOSURENOTICE:
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.
PLEASEDONOTRETURNYOURAPPLICATIONTOTHEABOVEADDRESS.
APPLICATIONSSHOULDBESUBMITTEDTOYOURUNIVERSITYPOINTOFCON TACT.
Page|2
DECEMBER2019
I.THISCHECKLISTISREQUIREDTOBETHEFIRSTPAGEOFTHEAPPLICANT
PACKAGE,ANDMUSTBESIGNEDBYTHESTUDENTAPPLICANTANDTHEPI.
StudentName:
C
urrent
Add
ress:
S
econ
d
Add
ress:
PhoneNumber
(
cell
)
PhoneNumber
(
LandlineorPermanent
)
:
S
tu
d
ent
S
c
h
oo
l
Emai
l
Add
ress:
Al
ternate
E
mai
l
Add
ress(gmail/yahoo/hotmail,etc….)
ALLCySPAPPLICANTSMUSTANSWERALLQUESTIONS
ACTIVITY/QUESTION
ITEMINCLUDED/
ANSWER
(Y/N)
STUDENT
INITIALS
P.I.
INITIAL
S
CURRENTU.S.Citizen:
OfficialTranscript(s)Provided:
CumulativeGPA–providescoreinnextcolumn
GPAMUSTmatchtranscripts.(NoRounding)
Currentlyenrolledoraccepted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andDistinctionslistattached
2LettersofReference:
Last Name Only:
✔
1
21
Page|3
DECEMBER2019
VeteranStatus:
Ifyestoabove,indicatewhether5or10yearstatus
Proofofeligibilityattached
OF612SupplementalInformationChart
(SectionII)
OF612SupplementalCompetencyStatement
SupplementalS tatementofGeneralAcademic
andEmploymentConditions
Depar
t
men
t
ofDefense(DoD)A gency Location Choices *(SeeSectionG,Paragraph10–Mayleave
blank)
AgencyLocationChoice#1
AgencyLocationChoice#2
AgencyLocationChoice#3
Iwouldbein
t
eres
t
edinac
t
ivedutymili
t
ary serviceas a meansto
meetingmyobligatedservicerequirements.(AnswerYesorNo)
1
IamcurrentlyamemberoftheNationalGuardoraReserveUnit: ___Yes ___No
StudentSignature:
StudentPrintedName:
P.I.Signature:
P.I.PrintedName:
1
Includes full-time active duty Guard and Reserves
click to sign
signature
click to edit
Page|4
DECEMBER2019
II. SupplementalInformation(Chart)
A. ApplicantsfortheCySPmustprovidecertaininformationabouttheiracademicstandingtoenableareviewof
academicsufficiencybytheappropriateNationalCentersofAcademicExcellenceinCybersecurity,hereinafter
referredtoasCAEs.Thissectioncontainstherequiredsupplementalinformationrequirements.YouMUST
provideALLrequiredinformationbelowtoreceivefullconsideration.Tobedeemedcompleteyoumust
obtainandattachcertainadditionalmaterialstothisstatement.Allinformationandmaterialthatyouattach
tothisstatementshallbecomepartofyourApplicationforFederalEmployment.
B. Providecompleteresponsestoallinformationrequirements,asapplicabletoyou,andattachtheadditional
documentsrequired.Signanddatethisstatementintheareaprovided.
BeginningintheFALLofAcademicYear2020-2021,
Iwillenterthefollowing:
DeclaredMajorforthedegreelevel/programyouarerequestingconsiderationbytheDoDCySPis:
Numberofcreditsearnedtodateforthisdegree:______________________________________________________________
Numberofcreditsrequiredforgraduationforthisdegree:__________________________________________________
C. IhavelistedallcollegesoruniversitiesIhaveattendedinSection2belowandhaveprovidedthenecessary
officialtranscripts.Donotincludethedegreeprogramlistedabove.(ifnecessary,provideadditional
institutioninformationonaseparatesheetattachedtothisform).
Institution State DatesAttended DegreeEarned GPA
Junior/Senior Year
Page|5
DECEMBER2019
Recognitions‐Honors‐Awards
Separatesheethighlightingrecognitions,honorsandawards: Attachaplain8½”X11”paperwithyour
nameandschool.Describeanyacademicrecognition(certificationsincluded),honors,distinctions,or
awardsthatyouhavereceived.Thisisveryimportant,asitcountstowardstheevaluationcriteria.
NOTE
Therecognition,honors,distinctions,orawardsthatyoudescribeinthissupplementalstatementneednot
bejob‐related.
Be sure that you include any scholarships, membership in any honorary societies to which you were
admitted because of academic accomplishment, and any significant leadership roles in academic groups,
organizations,societies,orassociationstowhichyouwerenominatedorelected.
Provide sufficient summary information for evaluators to understand the period or date of the
accomplishment,theawardinginstitutionororganization,andwhatyoudidtoearntherecognition.
DONOTATTACH:
a. CopiesofDegrees
b. CopiesofCertificates
c. CommemorativeMemorabilia
d. Compositions
e. Publications
f. PersonallyIdentifiableMedia(Driver’sLicense,SocialSecurityCards,MilitaryIDs,etc.)
D. Youmustattachtwo(2)LettersofReferencetothissupplementalstatementfrompersonsknowledgeable
ofyourpotentialforsuccessfullearning,aswellasyourknowledgeandability.Atleastoneoftheseletters
mustbefromacurrentfacultymember[oramostcurrentfacultymember],andthesecondlettermaybe
fromeitheracurrentorformerfacultymember,oracurrentorformeremployer.Eachlettermustcontain
thename,positionortitle,telephonenumber,emailaddress,andinstitutionalororganizationaladdressof
thereferee.Inaddition,youmustrequestthateachrefereerefertoandaddressthefollowingfactors:
a. Therelationshipoftherefereetoyou.(Therefereestateswhethertheinformationisbasedonanacademic
oremploymentrelationship.)
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,on
thelettersofreferencethatyousubmit.)
d. Anassessmentofyourknowledgeandabilityfollowingthesix(6)competencyareaslistedin
SectionFbelow.
E. Bysigningthissupplementalstatement,Iacknowledgethattheinformationgivenaboveistrueand
correct:
NAME:_________________________________________________________________________________________
SIGNATURE:___________________________________________________________________Date:_____________________________
click to sign
signature
click to edit
Page|6
DECEMBER2019
F. COMPETENCYSTATEMENT (OF612‐APPLICATIONFORFEDERALEMPLOYMENT
SUPPLEMENTAL)
Onplain8½”x11”paper,titleasabove,describeyourknowledgeandabilityineachofthesix(6)competency
areasbelow.Theevaluationpointsareveryhighinthisarea.Youmustaddresseachareaidentified.Ifyoudonot
providethisinformation,yourpackagewillbedeemednon‐responsiveandwillnotbeconsidered.
Indicateyournameandschoolnameoneachpage.
Limityourresponsesonallsixcompetencyareastoatotalofthreepages.
a. Knowledge
ofthetechniquesofthecybersecuritydiscipline,includingencryption,accesscontrol,physical
security,training,threatanalysis,andauthentication.
b. Knowledgeofthehumanfactorsincybersecurity,includinghumancomputerinteraction,design,training,
sabotage,humanerrorpreventionandidentification,personalusepolicies,andmonitoring.
c. Abilitytoidentifyandanalyzeproblems,distinguishbetweenrelevantandirrelevantinformationtomake
logicaldecisions,andprovidesolutionstoindividualandorganizationalproblems.
d. Abilitytoconsiderandrespondappropriatelytotheneeds,feelings,andcapabilitiesofdifferentpeoplein
differentsituations;istactful,compassionateandsensitive,andtreatsotherswithrespect.
e. Abilitytomakeclearandconvincingoralpresentationstoindividualsorgroups;listenseffectivelyand
clarifiesinformationasneeded;facilitatesanopenexchangeofideasandfostersanatmosphereofopen
commu
nicati
on.
f. Abilitytoexpressfactsandidea
sinwritinginclear,convincingandorganizedmannersappropriatetothe
audienceandoccasion.
Page|7
DECEMBER2019
F. OF612:
OPTIONALAPPLICATIONFORFEDERALEMPLOYME NT
SUPPLEMENTALSTATEMENTOFGENERALACADEMIC
AND
EMPLOYMENT
CONDITIONS
TobeconsideredfortheCyberScholarshipProgram(CySP),youmustagree
tocertain academic standards and
conditions of employment.This OF612 supplement describes
those conditions.Read thisstatement carefully,
and indicateyour elections, where appropriate.
When you understandalloftheconditionscompletely,andagree
withallofthem,signanddatethe
statement,andincludeitwithyourResumeandOF612Supplementalinformation.
1) Inordertoreceivefinancialassistance(ascholarship)orappointmentunderthe
DoDCyber Scholarship
Program, you must be enrolled (or accepted for enrollment)at one of
the institutionsofhighereducation
designatedbytheNationalCentersofAcademicExcellenceinCybersecurity (CAE-C), orenrolled (or
accepted
forenrollment)inaninstitutionselectedbyaCAE-Casacollaboratingpartnerinthe
Cyber Scholarship
Program.
2) In order to receive financial assistance (a scholarship) or appointment under the CySP,the CAE-Catwhich
youareenrolled(oracceptedforenrollment)mustsubmitasuccessfulgrantproposaltothe
DoDtoestablish
theCySPontheircampus.
3) Inordertoreceivefinancialassistance(ascholarship)orappointmentundertheCySP,youmustbeenrolled
(oracceptedforenrollment)inafull‐timeprogram
1
leadingtoanundergraduateormaster’s
degree, ordoctoral
degree,andpursuingacourseofstudyand/orhaveadeclaredmajor in one
ofthescientific,technicalor
managerial disciplines related to computer andnetworksecurity,witha concentration in a cybersecurity
function.(In accordance with 5CFR213.3202(b)(2),anindividualwhoneedstocompletelessthanthe
equivalent of half an academic course load in the
class enrollment period immediately prior to graduating is
still considered a student for
purposesofthisprogram.)
a) Cybersecurityencompassesthescientific,technical,andmanagementdisciplinesrequiredtoensure
computerandnetworksecurity,includingthefollowingfunctions:
System/networkadministrationandoperations
Systemssecurityengineering
Informationassurancesystemsandproductacquisition
Cryptography
Threatandvulnerabilityassessment,toincluderiskmanagement
Websecurity
Operationsofcomputeremergencyresponseteams
Computerforensics
Defensiveinformationoperations
Criticalinformationinfrastructureassu
rance
b) Relevantcyber‐relatedacademicdisciplines,withconcentrationsincybersecurity,wouldinclude,butarenot
limitedto:
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.
Page|8
DECEMBER2019
b. Administration
Computer:
a. CrimeInvestigations
b. Engineering
c. Forensics
d. InformationScience
e. InformationSystems
f. Programming
g.
Science
h. SystemsAnalysis
CriticalInformationInfrastructureAssurance
Cyber:
a. Defense
b. Operations
c. Security
d. Policy
Cryptography
DatabaseAdministration
DataManagement
DataScience
DigitalandMultimediaForensics
ElectricalEngineering
ElectronicsEngin
eerin
g
InformationAssurance
SystemsandProductAcquisition
InformationSecurity(Assurance)
InformationSystems
InformationTechnology:
a. Acquisition
b. Program/ProjectManagement
Math
em
atics
NetworkAdministrationandOperations
NetworkManagement
OperationofComput
erEmergencyResponseTeams
SoftwareEngineering
SystemsSecurityEngineering
ThreatandVulnerabilityAssessment,toincludeRis
kManagement
WebSecu
rity
AnyothersimilardisciplinesasapprovedbytheDoDChiefInformationOffice(DoDCIO).
4) Ifyouareanundergraduatestudent,youmustmaintainanoverall3.2outofa4.0gradepointaverage
(oran
analogousrankbasedonacomparablescale)inordertoreceivefinancialassistance(ascholarship)underthe
CySP.Ifyouareagraduatestudent,youmustmaintainanoverall3.5outofa4.0 (or an analogous rank based
on a comparable scale) in order to receive financial assistance (ascholarship).Failuretomaintainthese
minimumgradepointaveragesconstitutesgroundsfor
immediateterminationoffinancialassistanceand
yourappointmentundertheCySP.Additionally,ifyou fail to complete the degree program satisfactorily
ortofulfilltheservicecommitmentupongraduation,youshallberequiredtoreimbursetheUnited
States,inwholeorinpart,the
costofthefina ncial(scholarship)assistanceprovided.
5) Exceptforsmallachievementawards(nottoexceed$5,500inany academic year), you may notaccept
simultaneous remuneration from another scholarship or fellowship while receiving financialassistanceunder
Page|9
DECEMBER2019
theCySP.Ifyouareinagraduateprogram,youmayreceiveareasonableamountof
remunerationforteaching
orsimilaractivitiesasare,intheinstitution’sopinion,contributorytoyour
academic progress.Except where
state or local law, court or proper administrative order declares
otherwise,theDoDshallassumethatthe
developmentofstudents,notservicetotheacademic
institution,willgoverntheassignmentofthese
activities.
6) In order to receive financialassistance (a scholarship) under the CySP, you must agree to accepta federal
appointment under the authority to employ individuals completing Department of
Defense Scholarshipor
FellowshipProgram,oranother hiring authority. Youmaybe appointedunderthis programasaGS‐7,GS‐9,or
GS‐11basedonyourqualifications,andtheneedsandconditionsoftheappointingdefensecomponent. During
yourperiodofserviceunderthis
appointment,iftimingpermits,youmustacceptandperformintern
assignmentsdesignedtoenhanceyouracademicstudiesincybersecurity.These assignments will be scheduled
at times
mutually agreeable to you, yourschool,andtheDoDcomponentthatappointsyou.
7) Inordertoreceivefinancialassistance(ascholarship)undertheCySP,youmustagreetoworkfortheDoD,after
theawardofyourdegree,asacivilian*employeeforonecalendaryearforeachacademicyear,orpartialyear,
forwhichfinancialassistance(scholarship)isreceived.*Seeparagraph8forterms ofmilitaryservice, should
youdesire this option. This requirementiscalled
“obligated service”. The work you may perform during an
internship DOES NOT COUNT toward
satisfactionofyourobligatedservicerequirement.
8) Should you desire to enlist or accept a commission to serve on activedutyinoneoftheMilitary
Services
2
,
youmustincuraserviceobligationofaminimumof4yearsonactivedutyinthatService
upongraduation.The
MilitaryServicesmayestablishaserviceobligationlongerthan4years,dependingontheoccupationalspecialty
andtypeofenlistmentorcommissioningprogramselected..“Ifyouareinterestedinmilitaryserviceasameans
tomeetingyourobligatedservicerequirements,pleaseindicatethisinSection10ofthisapplication.
9) In order to receive financial assistance (a scholarship) or appointment under the CySP, you mustagreeto
bemobile.Uponappointment,youwillberequiredtosignanagreementtoacceptassignments
that
involvetravelorchangesindutystations,assignmentsindifferentorganizations,assignmentsindifferent
functionalareas,andassignmentsindifferentgeographicareas,duringyour
internship,ifapplicable,ANDduring
yourincumbencyofanypermanent,full‐timepositiontowhichyouare converted on program completion.
Yourtravelunderthis agreement, and the travelof allDoDcivilian employees, is governed by the Federal
Travel Regulations and the DoD Joint TravelRegulations.Theseregulationsprovidefortravelbenefits,and
payorreimbursementofyourtravelexpenses,onanincidental,case‐by‐casebasis;itisnotpossibletospecify
yourexactentitlementtotravelbenefitsatthistime.
10) TheDoDdoes not guarantee thatyourpreferencesforagencyassignment(orlocation)undertheCySP,orin
a permanent position to which you are subsequently converted, can be honored.
Your preferenceswillbe
takenintoaccount,alongwithallotherrelevantfactorssuchas:mission,functional, and staffing requirements;
the exigencies of service; the availability of funds;
and, any hardshipsyoumaydemonstrate. Nonetheless,
youragencypreferencesare
importanttothedepartment.Therefore,youmayspecifyuptothreeagency
preferencesbelow,ifyouwish.Youarenotrequiredtocompletethesepreferenceselections.Youmayspecify
cityandstateofpreference,ifknownaswell.ForinformationonDoDAgencies,youmayviewthefollowingweb
sitewhichcontainstheOfficeoftheSecretaryofDefense,Defense AgenciesandDoD Field
Activities,
OrganizationandFunctionsGuidebook:
http://www.defense.gov/about/
11) In order to receive financial assistance (a scholarship) under the CySP, you must agree toreimbursethe
UnitedStatesshouldyouvoluntarilyterminateyouremploymentwiththeDoDbefore
the end ofyourperiodof
obligatedservice. (Seealsoitem 7 above.) Should you terminate yourappointm ent undertheCySP,
declineorrefusetohonoryourcommitmenttoacceptpermanentemployment,or,voluntarilyterminate
permanentemploymentbeforeyouhave fulfilled yourperiod of obligatedservice,youmustreimburse
theUnitedStates,inwholeorinpart,thecostofthe financial (scholarship) assistance provided to you.An
obligation toreimburse under thisconditionofemploymentisforallpurposesconsideredtobeadebtowed
totheUnitedStates.
12) In order to receive financial assistance (a scholarship) or an appointment under the CySP, youmust agree
2
Includes full-time active duty Guard and Reserves
Page|10
DECEMBER2019
to sign certain forms authorizing a background investigation to permit the appointingagencyto
makeadeterminationastoyoursuitabilityforfederalemployment.
13) Youwillberequiredtoobtainandmaintaineligibilityforasecurityclearanceinordertoreceive financial
(scholarship) assistance or an appointment under the CySP. You may berequiredtoundergocertaintests,
includingdrugandpolygraphtests,toobtainandmaintainaclearance. Before you may be awarded a
scholarship orhired by DoD , you will be requiredto completecertainformstoinitiatethesecurityclearance
process.Someoftheseformswillrequirethatyourevealextensiveinformationaboutyourbackground,such
aspotentially sensitiveinformationaboutyourfinancialcircumstancesandanyarrestsand/orconvictions for
offensesofanykind.Youmustagreetoalloftheseconditionsofemployment
andyoumustcompletethese
formsasaconditionoffinancialassistanceandappointment.
Current web pages from the Office of Personnel Management (OPM) provided below. This is provided for your
review and consideration in determining whether you will be eligible for asecurity clearance. This may not be all
inclusive, however, it is highly recommended that youreview and understand the requirements prior to signing up
to participate in the DoD CySP.h
ttp:/
/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:
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Completed 22 July 2020

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