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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: