1.  Name:

________________________________________________________
(last) (first) (middle)

2. Present Address:

________________________________________________________
(number and street)

3. Permanent Address:

________________________________________________________
(number and street)

4. Date of Birth:

________________________________________________________

6. School and Community Activities; list any of the following you have received or are a member of (use additional paper if necessary):

a) Honor Societies

b) Organizations

c) Scholarships, stipends or fellowships

d) Prizes, awards, honor roll, deans list or other academic achievements

e) Evidence of non-scholastic recognition, achievements or awards

f) Other activities (sports, clubs, civic groups, etc.)

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

 7.  Name of college or institute of higher learning you are enrolled in as a full or part time student:

__________________________________________________________________________
(Full Name)

__________________________________________________________________________
(Number and Street)

__________________________________________________________________________
(City, State and Zip)

________________________________________________________

9. Why did you choose this major?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

10. What are your career plans?

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

11. Department Advisor

________________________________________________________
(Name)

(_____)___________________________________________________
(Phone No. and extension)

________________________________________________________
(Signature)

12. Is your transcript enclosed with the application?   yes _____    no _____

If not, why:
__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

13. Briefly explain how the money is going to be used toward your education:

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________