NATIONAL SCIENCE FOUNDATION

PRESIDENTIAL EARLY CAREER AWARDS FOR SCIENTISTS AND ENGINEERS (PECASE)

OFFICE OF SCIENCE AND TECHNOLOGY POLICY

INFORMATION FORM

The following information will be needed for the clearance required for presidential awards should you be recommended by the National Science Foundation to the Office of Science and Technology Policy (OSTP) as a nominee for a Presidential Early Career Award for Scientists and Engineers (PECASE). Read and sign this form under the Disclosure Statement and return it with your CAREER proposal.

FULL NAME:_______________________________________________________________

(include full middle name and any former name used)

SOCIAL SECURITY NUMBER*:________________________________________________

DATE OF BIRTH: ___________________________________________________________

PLACE OF BIRTH:___________________________________________________________

MARK ONE OF THE FOLLOWING:____ U.S. Citizen or National ____Permanent Resident

If you are a permanent resident have you applied for U.S. citizenship?___________________

PERMANENT ADDRESS (and CURRENT HOME ADDRESS, if different) AND TELEPHONE NUMBER:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

CURRENT EMPLOYER(S):____________________________________________________

DISCLOSURE STATEMENT

I, the undersigned potential PECASE nominee, by signing this form acknowledge that I have been informed that the information contained on this form and in the CAREER proposal will be available to those individuals directly involved in the review and award process at the National Science Foundation and the White House Office of Science and Technology Policy (OSTP). I authorize the disclosure of these materials to those individuals implementing the review and award process.

If permanent resident status is checked, I also authorize disclosure of identifying information from my CAREER proposal to the U.S. Immigration and Naturalization Service for the purpose of verifying permanent resident status.

_______________________________________________________________

Signature/Date

EFFECT OF NONDISCLOSURE: Submission of this information is voluntary. However, failure to supply the information or authorize these disclosures will result in your ineligibility for a PECASE award.

* Submission of your social security number is voluntary and will not affect eligibility for a PECASE award. However, it is integral to the processing of any Presidential award, including PECASE. SSN solicited under NSF Act of 1950, as amended.

NSF FORM 1317A (5-96)