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National Science Foundation z 4201 Wilson Boulevard z Arlington, Virginia 22230

ACCEPTANCE/DECLINATION FORM FOR NSF GRADUATE RESEARCH FELLOWSHIP
Please type or print. Use black ink. Please return one copy of this form, by April 30, 2001, to the Graduate Research Fellowship Program, National Science Foundation, 4201 Wilson Boulevard, Room 907N, Arlington, VA 22230.

Name: ___________________________________ __________________________________ _________________________ _____________ last first middle Jr., II, etc. Permanent U.S. residence address: _____________________________________ _____________________________ _______ ____________ street city state zip code Mailing address: ____________________________________ _____________________________ _______ _____________ street city state zip code

Summer address: _____________________________________ _____________________________ _______ ____________ street city state zip code Social Security Number: ______ – ______ – ______ Telephone number(s) (______) ____________________ (______) ____________________ Where you can be reached prior to beginning tenure.

My Internet e-mail address is/will be: ________________________________________________________________________________

Please indicate one: _______ I accept the fellowship award offered me. _______ I decline the fellowship award offered me.

Please affix your signature and the date in the space below and if declining the award, please give your reason(s) on page 2 of this form.

Graduate degree program: ________________________________ ______________________________ institution city

_______________ state or country

_____________________________________________ ______________________________________________________ field department My plan for the NSF fellowship during academic year 2001-2002 is to: _____ Begin tenure in the Summer Term, _____ Begin tenure in the Fall Term, _____ Reserve the first year (see page 2).

_____ One-Time International Research Travel Allowance for use in the 2001-2002 academic year.

Note: If you choose to start in the Summer Term, stipend payments through your chosen institution may be late. Consult your Information for Graduate Research Fellows booklet (available online at http://www.nsf.gov/grfp under “Publications”) for guidelines governing tenure reductions, reserving the first year and requesting the one-time $1,000 International Research Travel Allowance. . I understand and agree that the fellowship is made subject to the provisions set forth in the booklet entitled Information for Graduate Research Fellows (and of any amendments thereto), which is available online at http://www.nsf.gov/grfp under “Publications” and which I have read. _____________________________________________________ ________________________

SIGNATURE

DATE

Submission of social security number is voluntary. It is an integral part of the NSF information system and assists in processing the award. SSN solicited under NSF Act of 1950, as amended.

NSF Form 179(3/01) Supersedes All Previous Editions

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National Science Foundation z 4201 Wilson Boulevard z Arlington, Virginia 22230

ACCEPTANCE/DECLINATION FORM FOR NSF GRADUATE RESEARCH FELLOWSHIP
Please type or print. Use black ink.
Name: _________________________________ _____________________________________ __________________________ ___________________ last first middle Jr., II, etc.

If you are declining the NSF fellowship, please state your reasons. If you are accepting another fellowship, please tell us which other Fellowship and your reasons for accepting it over the NSF offer.

If you are requesting the one-time $1,000 International Research Travel Allowance for use in 2001-2002, please describe your plans. Also, specify the foreign site and the dates (or number of months) you plan to spend in research or study there.

If you are requesting to reserve your first year, please briefly describe your plans for the year as well as your plans to engage in graduate study subsequently.

NSF Form 179(3/01) Supersedes All Previous Editions

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INSTRUCTION ON CERTIFICATION OF NON-DELINQUENCY BY APPLICANTS FOR FEDERAL ASSISTANCE
Pursuant to OMB Circular A-129, “Except where required by law or approved by the head of the agency, no award of Federal funds shall be made to an applicant who is delinquent on a Federal debt until the delinquent account is made current or satisfactory arrangements are made between affected agencies and the debtor.” For the purposes of this certification, the following definitions of delinquency apply: Direct loans – a debt more than 31 days past due on a scheduled payment. Grants – recipients of a “Notice of Grants Cost Disallowance” who have not repaid the disallowed amount or who have not resolved the disallowance. Guaranteed and insured loans -- recipients of a loan guaranteed by the Federal Government that the Federal Government has repurchased from a lender because the borrower breached the loan agreement and is in default. Examples of debts include delinquent taxes, audit disallowances, guaranteed and direct student loans, housing loans, farm loans, business loans, Department of Education institutional loans, benefit overpayments and other miscellaneous administrative debts.

INSTRUCTIONS ON CERTIFICATION REGARDING DEBARMENT AND SUSPENSION

1. The inability of a person to provide the certification will not necessarily result in denial of participation in this covered transaction. The applicant shall submit an explanation of why it cannot provide the certification. The certification or explanation will be considered in connection with the department or agency’s determination whether to enter into this transaction. However, failure of the applicant to furnish a certification or an explanation shall disqualify such person from participation in this transaction. 2. The certification in this clause is any material representation of fact upon which reliance was placed when the department or agency determined to enter into this transaction. If it is later determined that the applicant knowingly rendered an erroneous certification, in addition to other remedies available to the Federal Government, the department or agency may terminate this transaction for cause of default. 3. The applicant shall provide immediate written notice to the department or agency to whom this application is submitted if at any time the applicant learns that its certification was erroneous when submitted or has become erroneous by reason of changed circumstances. 4. The terms “covered transaction,” “debarred,” “suspended,” “ineligible,” “lower tier-covered transaction,” “applicant,” “person,” “primary covered transaction,” “principal,” “proposal,” and “voluntarily excluded,” as used in this clause, have the meanings set out in the Definitions and Coverage sections of the rules implementing Executive Order 12549. You may contact the department or agency to which this application is being submitted for assistance in obtaining a copy of those regulations. 5. Covered transactions are of two types: primary and lower tier. A primary covered transaction is any nonprocurement transaction between an agency and a person, regardless of type, including: grants, cooperative agreements, scholarships, fellowships, contracts of assistance, loans, loan guarantees, subsidies, insurance payments for specified use, donation agreements and any other nonprocurement transactions between a Federal agency and a person. Primary covered transactions also include those transactions specially designated by the U. S. Department of Housing and Urban Development in such agency’s regulations governing debarment and suspension. A lower tier covered transaction is: a. Any transaction between an applicant and a person other than a procurement contract for goods or services, regardless of type, under a primary covered transaction. b. Any procurement contract for goods or services between an applicant and a person, regardless of type, expected to equal or exceed the Federal procurement small purchase threshold fixed at 10 U.S.C. 2304(g) and 41 U.S.C. 253(g) (currently $25,000) under a primary covered transaction. c. Any procurement contract for goods or services between an applicant and a person under a covered transaction, regardless of amount, under which that person will have a critical influence on or substantive control over that covered transaction.

(PLEASE CERTIFY ON REVERSE SIDE.)

CERTIFICATIONS PAGE
There are three certifications which must by law be made before the National Science Foundation can authorize funds for a fellowship award. These concern 1) controlled substances; 2) delinquency on Federal debt; and 3) debarment and suspension. (See instructions on reverse side.)

CERTIFICATIONS
I certify that: 1. I will not engage in unlawful manufacture, distribution, dispensing, possession or use of a controlled substance in the conduct of any activity with this fellowship award; I am not delinquent on repayment of any Federal debt, and To the best of my knowledge and belief: (a) I am not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from covered transactions by any Federal department or agency; (b) I have not within a three-year period preceding my application been convicted of or had a civil judgment rendered against me for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State, or local) transaction or contract under a public transaction; violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; (c) I am not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State or local) with commission of any of the offenses enumerated in paragraph (3) (b) of this certification; and (d) I have not within a three-year period preceding this application had one or more public transactions (Federal, State or local) terminated for cause or default.

2. 3.

________________________________________________ Printed Name

________________________________________________ Signature Date Please return one copy of this form, by April 30, 2001, to the Graduate Research Fellowship Program, National Science Foundation, 4201 Wilson Boulevard, Room 907N, Arlington, VA 22230.