Coast Guard Foundation Scholarship Application Uscg Cg6054 Page 2
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2Page 2 of CG-6054 (12-05)
EMPLID NO. Verification
Coast Guard Foundation
Scholarship Application
CG-1112 only
Coast Guard Sponsor Data:
Pay Grade:
Rank:
Employee ID (Do not give your social security number)
Last Name:
First Name:
MI:
Coast Guard Unit:
City:
State:
District:
Area:
Sector:
ISC:
Yes No
Active Duty (If yes, date entered on active duty)
Reserve on extended active duty (If yes, give start date of present duty assignment)
Retired (If yes, date of retirement from the Coast Guard)
Deceased (If yes, provide date)
Print Name (Father):
Tel #
Print Name (Mother):
Tel #
Student/ Sponsor Certification:
We certify that, to the best of our knowledge, all responses are true and factual, the sponsor, as well as the applicant, has
reviewed the eligibility requirements. We verify the applicant is unmarried and has not reached the age of twenty-three (23)
on this day. We also agree, if the applicant is selected as a scholarship recipient, applicant, parent and sponsor name,
along with sponsor duty location will be used for purposes of news and publicity of the Coast Guard Foundation
Scholarship Program by Commandant (CG-1112) and the Coast Guard Foundation for current and future promotions of the
scholarship program.
Signature of Applicant:
Date:
Print Name:
Signature of Sponsor:
Date:
Print Name:
5 U.S.C. 552(a) Privacy Act
a. AUTHORITY: 5 U.S.C. § 301 Departmental Regulations
b. PURPOSE: To collect information for the purpose of processing requests for consideration for award of a Coast Guard Foundation
Scholarship.
c. ROUTINE USES: Used in the performance of official duties related to the processing of scholarship documents. Viewed by the selection
panel and Coast Guard Foundation staff.
d.
DISCLOSURE: Voluntary; however failing to provide the information may result in disqualification from consideration for award of a Coast
Guard Foundation scholarship.
U.S. DEPT. OF HOMELAND SECURITY, USCG, CG-6054 (Rev. 12-05)
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