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SCHOLARSHIP APPLICATION
Incomplete applications and those postmarked after the deadline will not be considered
Scholarship Title ____________________________________________ Application Year __________
Name ______________________________________ Social Security No. ________________________
Address ____________________________________________________________________________________
City State Zip Code
Best phone number to contact you: ____________________________
How long have you lived at the above address? ________ Years ________ Months If less than (6) months, list previous address:
Address _____________________________________________________________________________
City State Zip Code
Parents Names: Father ___________________________ Mother ____________________________
High School ________________________________________ Last Attended ____________________
Year of Graduation or Completion of GED Certificate _________ (Submit High School Transcript and/or GED Scores)
Reg. ACT/ENHANCED ACT score _____ High School Rank ______ Out of ______ Basic Skills Score _____
List any other colleges previously attended: (Submit Grade Transcripts)
___________________________________________________________________________ _____________
College Address City State Zip Code Years Attended
___________________________________________________________________________ _____________
College Address City State Zip Code Years Attended
If you have been away at least five (5) years, please attach a written explanation to this application clearly stating how your activities (life experiences) provided academic skills and knowledge otherwise reflected through test scores, grades or class rank.
List hobbies and/or active interests in local organizations ____________________________________________________________________________________________
____________________________________________________________________________________________
Place of Employment __________________________________________________________________________
Employer Address City State Zip Code
Occupation ________________________________ Career oal________________________________Academic Goal: (Circle One) Certificate Associates Degree Beyond Associate Degree
Other; Explain: _________________________________________________
Program of Study _______________________ Hours Completed at ___________________________________
Cum. Grade Point Average at ___________ Academic Level: (Circle One) Freshman Sophomore Junior Senior Other _______________________________
Planned Enrollment at _________________________________________________
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