Fillable NEW STUDENT APPLICATION DoD Cyber Scholarship Program (Davenport University)

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NEW STUDENT APPLICATION DoD Cyber Scholarship Program (Davenport University)

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P a g e | 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.

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OCTOBER 2020

I. THIS CHECKLIST IS REQUIRED TO BE THE FIRST PAGE OF THE APPLICANT PACKAGE,

AND MUST BE SIGNED BY THE STUDENT APPLICANT AND THE PI.

Student Name:

Current Address:

Second Address:

(current residence)

Phone Number

(cell)

Phone Number

(Landline or Permanent):

Student School Email Address:

Alternate Email Address (gmail / yahoo / hotmail, etc….)

ALL CySP APPLICANTS MUST ANSWER ALL QUESTIONS

ACTIVITY/QUESTION

ITEM INCLUDED / ANSWER

(Y/N)

STUDENT

INITIALS

P.I.

INITIALS

CURRENT U.S. Citizen:

Currently enrolled or accepted for enrollment, at a CAE:

Cumulative GPA – provide score in next column

GPA MUST match transcripts. (No Rounding) You only need to provide the

transcript for the GPA you are claiming.

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 (Comm College/Undergrad,

Undergrad/Grad, Masters/PhD)

Single

Dual

Community

College

Bachelor’s

Master’s

PhD/Doctorate

ANTICIPATED FINAL GRADUATION DATE of the degree program(s)

identified above. Students must have at least one full academic year

remaining to apply

Month / Year

✔

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OCTOBER 2020

Checklist: Packages without the following application forms and information will be deemed incomplete and will not be considered.

(Y/N)

ITEM INCLUDED

STUDENT INITIALS

P.I.

INITIALS

Official Certified Transcript(s):

Resume (template provided):

Recognitions, Honors, and Awards:

Two (2) Letters of Reference:

Section F - OF612 Supplemental Competency

Section G - Supplemental Statement of General Academic

and Employment Conditions (Page 7 -10) Students should read and

sign at the end of page 10.

Department of Defense Agency Location Choices *(See Section G, Paragraph 10 – May leave blank)

I understand that if selected I may be required to physically move for summer internships and/or

final placement so that I am geographically located with a DoD Agency. (Answer Yes or No)

Agency Name

City

State

Agency Location Choice #1

Agency Location Choice #2

Agency Location Choice #3

Veteran Status: (Please redact any Personally Identifiable Information from your documents). Additional information can be

found here: https://www.fedshirevets.gov/job-seekers/veterans-preference/

Indicate whether 5 or 10 year status

Proof of eligibility attached

Currently a member of the National Guard or a Reserve Unit:

I would be interested in active duty military service as a means to meeting my obligated service

requirements. (Answer Yes or No)

Student Signature:

Student Printed Name:

P.I. Signature:

P.I. Printed Name:

Includes full-time active duty Guard and Reserves

LAST NAME ONLY:

YES

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P a g e | 4

OCTOBER 2020

II. Supplemental Information (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.

Beginning in the FALL of Academic Year 2021-2022,

I will enter the following:

Declared Major for the degree level/program you are requesting consideration by the DoD CySP is:

Number of credits earned to date for this degree: ______________________________________________________________

Number of credits required for graduation for this degree: __________________________________________________

C. (Do not include the degree program listed above) I have listed all colleges or universities I have attended in

Section 2 below. I have provided the necessary official transcripts that reflects my current GPA as listed on

Page 2 of this application. (if necessary, provide additional institution information on a separate sheet

attached to this form).

Institution

State

Dates Attended

Degree Earned

GPA

LAST NAME ONLY:

1st Year Masters

P a g e | 5

DECEMBER 2018

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

The recognition, honors, distinctions, or awards that you describe in this supplemental statement need not

be job-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, or associations to which you were nominated or elected.

Provide sufficient summary information for evaluators to understand the period or date of the

accomplishment, the awarding institution or organization, and what you did to earn the recognition.

DO NOT ATTACH:

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. You must attach two (2) Letters of Reference to 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 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, on

the letters of reference that you submit.)

d. An assessment of your knowledge and ability following the six (6) competency areas listed in

Section F below.

E. By signing this supplemental statement, I acknowledge that the information given above is true and

correct:

NAME: _________________________________________________________________________________________

SIGNATURE: ___________________________________________________________________Date: _____________________________

LAST NAME ONLY:

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P a g e | 6

DECEMBER 2018

F. SUPPLEMENTAL COMPETENCY (OF612 -APPLICATION FOR FEDERAL EMPLOYMENT

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

communication.

f. Ability to express facts and ideas in writing in clear, convincing and organized manners appropriate to the

audience and occasion.

LAST NAME ONLY:

P a g e | 7

OCTOBER 2020

G. OF612:

OPTIONAL APPLICATION FOR FEDERAL EMPLOYMENT

SUPPLEMENTAL STATEMENT OF GENERAL ACADEMIC AND

EMPLOYMENT CONDITIONS

To be considered for the Cyber Scholarship 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, and include 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

designated by the National Centers of Academic Excellence in Cyber Education (Cyber Defense and Research),

or National Centers of Academic Excellence in Cyber Operations, hereinafter referred to as CAEs, or enrolled

(or

accepted for enrollment) in an institution selected by a CAE as a collaborating partner in the

Cyber

Scholarship Program.

2) In order to receive financial assistance (a scholarship) or appointment under the CySP, the CAE at 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

leading to a 2-year Associates/4-year undergrad, 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.

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 assurance

b) Relevant cyber-related academic disciplines, with concentrations in cyber security, would include, but are not

limited to:

 Biometrics

 Business:

a. Management

b. Administration

 Computer:

a. Crime Investigations

b. Engineering

c. Forensics

d. Information Science

LAST NAME ONLY:

P a g e | 8

OCTOBER 2020

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 Engineering

 Information Assurance

 Systems and Product Acquisition

 Information Security (Assurance)

 Information Systems

 Information Technology:

a. Acquisition

b. Program/Project Management

 Mathematics

 Network Administration and Operations

 Network Management

 Operation of Computer Emergency Response Teams

 Software Engineering

 Systems Security Engineering

 Threat and Vulnerability Assessment, to include Risk Management

 Web Security

 Any other similar disciplines as approved by the DoD Chief Information Office (DoD CIO).

4) If you are a community college student, you must maintain an overall 3.0 out of a 4.0 grade point average (GPA),

an undergraduate student, you must maintain an overall 3.2 out of a 4.0 GPA, or a graduate student, you must

maintain a 3.5 out of 4.0 GPA.

(or an analogous rank based on a comparable scale) in order to receive financial

assistance (a scholarship) under the CySP. Failure to maintain these minimum grade point averages

constitutes grounds for

immediate termination of financial assistance and your appointment under the CySP.

Additionally, if you fail to complete the degree program satisfactorily or to fulfill the service

commitment upon graduation, you shall be required to reimburse the United States, in whole or in part,

the

cost of the financial (scholarship) assistance provided.

LAST NAME ONLY:

P a g e | 9

OCTOBER 2020

5) Except for small achievement awards (not to exceed $6,000 in any academic year), you may not accept

simultaneous remuneration from another scholarship or fellowship while receiving financial assistance under

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

you must incur a service obligation of a minimum of 4 years on active 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 indicate this on page 3 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 travel benefits, and

pay or reimbursement of your travel expenses, on an incidental, case-by-case basis; it is not possible to specify

your exact entitlement to travel benefits at this time.

10) The DoD does not guarantee that your preferences for agency assignment (or location) under the CySP, or in

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/

Includes full-time active duty Guard and Reserves

LAST NAME ONLY:

P a g e | 10

OCTOBER 2020

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 your appointment unde r the CySP,

decline or refuse to honor your commitment to accept permanent employment, or, voluntarily terminate

permanent employment before you have fulfilled your period of obligated service, you must reimburse

the United States, in whole or in part, the cost of 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, you must agree

to sign certain forms authorizing a background investigation to permit the appointing agency to

make a determination as to your suitability for federal employment.

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 conditions of 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 a security clearance. This may not be all inclusive,

however, it is highly recommended that you review and understand the requirements prior to signing up to

participate in the DoD CySP. https://nbib.opm.gov/e-qip-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:

LAST NAME ONLY:

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