George J. Mitchell Peace Scholarship

Application Form

All application materials must be postmarked or delivered to the Center for Career Development at the address below by February 15, 2008. Closure of the Center for the weekend, a holiday, or bad weather means that hand-deliveries must be made before February 15. Applications submitted after the deadline cannot be considered. Blank forms may be copied, but signatures must be original. Please note: Faxed or emailed applications will not be accepted.

Please print this form and mail or deliver your application to:

Center for Career Development—Peace Exchange

Maine Community College System

2 Fort Road

South Portland, ME 04106

Phone: (207) 767-5210, x4117

Would you accept a scholarship for one semester? Yes ___ No___

Would you accept a scholarship for the full academic year? Yes___ No ___

Legal name (first, middle initial, last)___________________________________________

Name as you would want it to appear on the award certificate (if different from above)

_______________________________________________________________________

Maine address

Street______________________________ PO Box______________________

City/town___________________________ Zip code ______________________

Daytime phone _______________________ Evening phone _________________

Fax (if available) _______________________ Email _______________________

Home address (if different from above)

Street____________________________________ PO Box________________

City/town_________________________________ Zip code _________________

Date of Birth: (Month/Day/Year)____________________________

Emergency contact:

Name________________________________ Relationship to you _______________________

Daytime phone ________________________ Evening phone _____________________

Address (If different from yours)

Street____________________________________ PO Box________________

City/town_________________________________ Zip code _________________

Do you have health and accident insurance that will cover you while you are abroad?

Yes ___ No ___ (Having this insurance is a requirement of the exchange.)

Do you have a valid passport? Yes ___ No ___ (You must have a valid passport before you leave the United States.)

Are you a U.S. citizen? Yes ___ No ___ If no, then of what country? _______________

Have you ever traveled outside the United States? Yes ___ No___ If so, where? For how long?

________________________________________________________________________

Educational status

I am currently attending ___________________ Community College

I will graduate in (month/year) from ____________________ Community College

GPA__________

I graduated in May of (year)__________from _________________________ Community College

GPA__________

My major program of study ____________________________________________________

Academic Advisor ________________________________ Title ____________________

Daytime phone __________________ Eve. phone_________________Fax _____________

Email _________________

List your professional, community, or school activities/organizations. Include any offices held.

________________________________________________________________________

List the names, titles, telephone numbers, and email addresses of the people whose letters of recommendation are attached. At least one writer should be affiliated with the Maine Community College System and be familiar with your academic ability. Another should recommend you for community service.

1. Name ______________________________ Title __________________________________

Daytime telephone________________________________ email _________________________

2. Name _______________________________ Title __________________________________

Daytime telephone ________________________________ email_________________________

3. Name ______________________________ Title __________________________________

Daytime telephone________________________________ email__________________________

List the program or major and courses you want at Cork Institute of Technology.

(Use a separate sheet if you need more room.)

Program/Course possibilities

___________________ _____________________________ _______________________

How do you plan to incorporate these courses into your education or career plans?

______________________________________________________________________

Attachments:

Essay

On separate paper, typed, please explain, in 500 words or less, why you should be awarded a George J. Mitchell Peace Scholarship. Include 1) how this exchange with Ireland will benefit you personally; 2) how it will contribute to your career plans; 3) why and how you feel prepared to live and study in another culture, in Ireland in particular; and 4) how you will use this experience to benefit others through leadership and community service.

Résumé (complete and up-to-date)

Official Community College Transcript (most recent)

Signatures

Scholarship applicant: I certify that the information presented in this application is true and complete.

Name (please print) ___________________________________

Signature ____________________________________________ Date _________________

Academic advisor: I certify that the program and courses included here have my approval and, upon satisfactory completion, may receive comparable Maine course credit.

Name (please print) ______________________________ Title ______________________

Signature ____________________________________________ Date _________________

Completed application checklist:

Irish program and courses of interest

Link to further education/career

Essay

Résumé

Official Community College transcript

Three letters of recommendation

Your signature

Your faculty advisor's signature

Maine Community College System

George J. Mitchell Peace Scholarship

Award Agreement

Recipient name ______________________________

Maine institution _____________________________

As a recipient of the George J. Mitchell Peace Scholarship Award for study at Cork Institute of Technology in Cork, Ireland, for the 2008-2009 academic year, I have been recognized for my academic achievements, leadership potential and skills, and commitment to community service. As a George J. Mitchell Scholar, I understand that successful completion of my exchange program in Ireland requires my acceptance of the conditions below.

Conditions of acceptance of the Peace Scholarship award:

Enroll full-time each semester at the Irish host institution during the period of the award.
Complete a formal written and oral evaluation of my exchange experience upon my return from Ireland.
Share my exchange experience formally and informally on campus and in the community (e.g., with future applicants, in international forums, and with civic associations such as Rotary).
Allow the Maine Community College System to release my name, hometown, high school, and photograph for MCCS and Mitchell Scholarship publicity, e.g., press releases and Web site, and grant MCCS permission to quote from my reports.
Communicate with the International Programs Coordinator at the Center for Career Development and the International Office at Cork Institute of Technology to—1) verify my arrival schedule; 2) verify my arrival in Cork; 3) report at least monthly on academic and social life at CIT; 4) let the MCCS International Programs Coordinator and the International Officer at CIT know if I plan to travel outside Ireland; and 5) verify my departure schedule at exchange completion.

By my signature, I indicate acceptance of these conditions.

______________________________________________
Recipient Signature

_________________________
Date