Postsecondary Administrator
Division of Basic Education & Accreditation
Department of Education PO Box PS87
Palikir, Pohnpei FM 96941

The supporting documents that should accompany this application are:

1) An acceptance letter or proof of attendance from your prospective institution,
2) An original copy of your transcripts,
3) A copy of the photo page of your passport, and
4) Three (3) letters of reference which will be sent directly to the Postsecondary Administrator.

And make sure that the Director of Financial Aid or his/her designee certifies costs of attendance, signs and impresses school zeal on the application form.

PART A: Personal Information
 
1. Type of Assistance Requested:

Graduate Scholarship
Other National Scholarship

2. Applicant's Name: 3. Gender: Male  Female
                                     Last Name                      First Name                      MI

4. Date of Birth: _______________ 5. Citizenship: □FSM    □FSM & USA Month/Day/Year

6. Applicant's Mailing Address: ______________________________________________________________________

7. Current Residency:___________________________________   8. Legal Residency: ________________________

9. Social Security Number: FSM __________________________ USA ______________________________________

10. Telephone No.: ____________________________  11. Email Address: __________________________________

PART B:  Legal Information

1. Applicant’s Legal Guardian's Name: ________________________________________________________

2. Relationship to You: ______________________ 3. Current Residency: ____________________________

4. Address of Legal Guardian: _________________________________ 5. Telephone: __________________

6. Email: _________________ 7. No. In Household: _____

8. Guardian Employed: □Yes □No     If yes, state occupation: ______________________________________

9. Place of Work: _____________________________ 10. Income: ________________________________

PART C:  Financial Information

1. Period of Study:  □Quarter     □ Semester   □ Full-Time Student   □ Part-Time Student
□ Fall          □Spring         □ Summer             □Winter

2 Expected Date to Begin Study: _____/______ /_______

3. Name and Address of Institution Accepting Applicant: ________________________________________
School Name


      ___________________________________________________________________________________________________________________________________________________
Address     City/State     Zip Code

4. Major: __________________________ 5. Expected Date of Completion: ________________________
 
6. Proof of Admission:  □Letter of admission or acceptance   □ I-90 Form Enclosed  □ Other proof

PART D:  Education and Achievements
 
1. Name and Address of School Last Attended:________________________________________________

_________________________________________________________________________________

List of at Least three Institutions Last Attended, If more than one. (Secure transcripts and letters from each of the institutions)
Name & Location of Institution Period of Attendance Degree (s) or Credit Hours Field or Major
   
   
   
NOTE:  Each letter of recommendation from institution must bear the signature of the official school representative(s) and/or the Counselors.


                 
2Date of Graduation: _________ 3. Cumulative Grade: ________  □ Honors     □ Above Average  □ Dean list    □ Average
  Grade Point Average 



PART E: Estimated School cost of Attendance Per Annum (Cost Breakdown)

1. Tuition and Fees $
2. Transportation $
3. Extra Curricular Activities $
4. Insurance $
5. Room & Board  Dormitory  Off-Campus $
6. Textbooks & Supplies $
7. Sub-Total 
8. Others 
9. Grand Total 
 


OTHER FINANCIAL AWARDS (PELL Grant, Scholarship, Student loans & Others) AND SOURCES.
NOTE: The applicant must list all of his/her sources and amount of financial assistance below.

1.  Name/Title of Awards 
2.  Name of Sources 
3.   Amount 
4.   Fiscal Year

   
   
   


CERTIFICATION:

I, the Director of Financial Aid or my designee, hereby certifies that the costs of attendance and the financial assistance provided in this application are, to the best of my knowledge and belief true and accurate.

________________________________  ______________________________
Print Your Name       Signature

 

_______________________________________  _____________________________________
 Official Title      Date

 


Name & Address of Institute Contacts
 Telephone number: 
 Facsimile Number: 
 Website 
 Email Address: 


PART F:  Student’s Goal

EDUCATIONAL GOAL: Describe your educational goals or ambitions, and explain why you think the field you are pursuing is important and how you think this will impact on your community. Be brief and concise. Indicate whether or not you will return to the FSM immediately following your graduation or not. Use additional sheet if necessary.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


STUDENT CERTIFICATION:

I, hereby certify that the information and supporting documents provided herein are true and correct to the best of my knowledge and belief.


____________________________________________   _______________________
Applicant’s Signature:         Date:


Note:  If the applicant is below (18) years old, then the School Official or Counselor shall affix his/her signature on this application, verifying the authenticity and his/her support of the applicant.

 

____________________________________________   ________________________
School Official/Counselor’s Signature:       Date:

 

FSM Official receiving this application with its supporting documents:


Name: __________________________________________   Date: ___________________


Missing supporting documents:  1) _____________________________ 2) _______________________________

3) _____________________________ 4) _______________________________

 

 


SAF-Form NSB-11-03

 

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