Name:______________________________________ Telephone: (____)_________________
Permanent Residence:___________________________________________________________
City:________________________ State
& Zip:________________
E-Mail Address: ________________________________________
Date of Birth:______________ Gender:
M / F Social Security
Number:_________________
Languages:________________________________________________________________________
High Schools Attended:______________________________________________________________
Academic record – self reported and transcript:
__________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Other than through classes in school in what areas
(non-academic or academic) have you
acquired knowledge or skills? How?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Honors, Awards, Community Service, Employment &
Leadership: ___________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Unpaid volunteer work & community service:
____________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Leadership Roles: __________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Do you have personal circumstances that keep you from
participating in community service or
leadership activities?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Discuss your short and long term goals. Are some of them related? Which are
priorities? _________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
For what purpose do you wish a scholarship? ___________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What is the total cost of the program? _________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How will you be paying for any amount not covered by this scholarship? ______________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What will be the long-term benefit of the program? _______________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Is there anything else you would like to tell us about that may help us evaluate your nomination,
i.e. personal characteristics, obstacles you have overcome, etc.?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Contact Information for Scholarship: Patricia
Volkerts Ph.D, Scholarship Coordinator
Mailing Address for Scholarship Information:
Attn:
Scholarship Coordinator