Farzaneh, Mateo

The Mossadegh Scholarship in the CAS, Fall 2019 General Information Name: _____________________________ Address: ___________________________ City: _________ State: ____ Zip Code: ______ Phone Number: ____________________ Email Address: ___________________________________ Undergraduate/Graduate Student (circle one) Cumulative GPA: _____ Total completed units: ______ Major at COBM: ______________ Graduation date: _______ Iranian and International/Iranian descent/Undocumented Student (circle one) IMPORTANT: ONLY electronic submissions are accepted by October 4, 2019. No hardcopies. After you complete the above information section and print your essay, you must scan and send your packet to The Mossadegh Initiative Principal Dr. Mateo Farzaneh at M-Farzaneh@neiu.edu no later than Friday, October 4, 2019. In addition to email he can also be reached at x5821. Electronic Scholarship Application Certification I, _____________________, certify that all information provide on this application is complete and accurate to the best of my knowledge. I authorize the Office of Institutional Advancement to verify the information that is contained on this application and to release the information provided on this application to those individuals involved in the selection process. I understand that any false statements, untruths or plagiarism will result in my forfeiture of the scholarship should I be selected as the recipient. Also, I understand that any false statements, untruths or plagiarism will result in my returning any/all monies awarded to me from the Mossadegh Scholarship at CAS. Deadline October 4, 2019 �