FALL 2018 - SPRING 2019 Name* First Last Last 4 of Social Security Number:*Email Address:* Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Date of Birth* PREVIOUS EDUCATION: Add information about the school and year you just finished College/University*Location*Cumulative Hours*GPA*[Attach OFFICIAL Transcript(s)]* OUTSIDE ACTIVITIES HONORS: [Attach additional page(s) if needed] EMPLOYMENT BACKGROUND: Company*Type of Work*Date* CompanyType of WorkDate [Attach additional page(s) if needed] MILITARY BACKGROUND: Service BranchDate RankType of DischargeCHARACTER REFERENCES: (minimum of 2 - no relatives) Name* First Last PhoneProfession*Name* First Last Phone*Profession* COLLEGE PLAN: (12 hrs. minimum per semester for undergraduate and 9 hrs. minimum per semester for graduate school) Official Enrollment StatusOfficial Enrollment Status*GraduateUndergraduateGraduate options:*First yearSecond yearUndergraduate options:*SophomoreJuniorSeniorHours scheduled for Fall:*Please enter a value between 12 and 40.Hours scheduled for Spring:*Please enter a value between 12 and 40.If scheduled hours are under 12 hours please explain belowDegree w/ Major:*Expected Graduation Date* UNIVERSITY INFORMATION:Add information about the school you will be attending this upcoming year Attach OFFICIAL Fall Class ScheduleUniversity:*Scholarship Director:*Email Phone*Address* Street Address City State / Province / Region ZIP / Postal Code By typing your name below, the applicant attests to the accuracy of the information provided and authorizes the Scholarship Committee to substantiate any of this information. False statements shall be cause for immediate cancellation of the scholarship at any time.Print Name*Upload your picture.Applicant Electronic Signature:*Date* NOMINATING MEMBERS EMAIL: Email*
