PLEASE READ AND RESPOND TO ALL OF THE SECTIONS OF THIS FORM REGARDING YOUR OBLIGATIONS AS A NEVADA NASA SPACE GRANT AWARD RECIPIENT. THIS FORM MUST BE SUBMITTED IN ORDER FOR AN AWARD TO BE DISBURSED.

Please read and sign-off on each question below. Your name provided for all the questions below requiring signature and the electronic submission of this form confirms your understanding and willingness to abide by all of the following programmatic requirements.

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* 1. As a Nevada NASA Space Grant award recipient, you are expected to participate in Consortium activities, as well as submit a short academic profile which can be published on our NSHE website as well as a jpg photograph (head shot with clear image of yourself - in the lab or field please). In signing below, you agree to allow us to post this material on our website as well as our Space Grant newsletter. Please send this to the Nevada Space Grant office at nvspacegrant@nshe.nevada.edu

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 2. TAXABILITY OF AWARD. For all scholarship, fellowship or internship awards you receive, you will need to determine the amount which is subject to taxation. This will be the amount of the award in excess of the amount of your tuition, fees, books, supplies and equipment required for your degree program. You should keep receipts for all of these items to offset the amount of your award when you file your next federal income tax return. It is your responsibility to report this information to the IRS. 

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 3. The Nevada NASA Space Grant Consortium has permission to share your application for the purpose of reporting and photographs for the purpose of public relations. Your academic status will be shared with designated officials for the purpose of awarding and maintaining satisfactory academic progress.

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 4. To ensure timely receipt of Nevada NASA Space Grant Consortium communications, please add nvspacegrant@nshe.nevada.edu to your school and personal email address books. It is your responsibility to keep the Nevada NASA Space Grant Consortium informed of any address changes (including a current email address). As an award recipient, a current email address is essential for us in order to provide NASA with necessary information for their reports. NASA is very keen to know to what extent these programs/awards make an impact in a students academic/career choices. Therefore, you agree to submit updates on your education/career track during school and after graduation.

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 5. As a participant in the Nevada NASA Space Grant Consortium award program, you will be required to submit a progress report at the end of each semester or summer of the award period - depending on the nature and timing of your award. 

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 6. To remain eligible, you must maintain full-time status (as determined by your institution) for the awarded semesters, maintain a cumulative GPA of 3.0 or above, and remain in a science-based or science education-based degree program.

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 7. I certify that I am a U.S. Citizen

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 8. I hereby certify I have read the award requirements guidelines within and I understand and accept all conditions specified.

My signature in the space provided here affirms that I have read and agree to abide with the above requirement.

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* 9. In the space provided here, I've typed in my NSHE Student Identification Number

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* 10. Date form completed and submitted:

Date

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* 11. Please note in the space below the type of award are receiving:

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* 12. Please note in the space below the amount of award you are receiving. *
(i.e. $2000 for one semester; $5000 for XX number of weeks; $21,000 for two semesters etc)

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* 13. Please provide the name of your advisor/mentor and his/her institution and department. *
(i.e. Dr. John Smith, UNR, Physics)

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