APPLICANT
Name	Last First				ÿ Male ÿ Female	Social Security No.
Address City/State/ZIP					Date of Birth	MM/DD/YY
					Home Telephone	( )
Parent/Guardian				Your e-mail
High School				High School Address
College Counselor				High School Phone Number
College you plan to attend				Planned Major Field of Study
GPA Weighed 4.0 scale	Ethnic Group (optional) *check all that apply:	ÿ African American, Black ÿ Asian American (original country__________) ÿ Asian (country________) ÿ Hispanic, Latino ( country__________) ÿ Mexican American, Chicano ÿ Native American, Alaska Native ÿ Native Hawaiian, Pacific Islander ÿ Puerto Rican ÿ White or Caucasian ÿ Other (specify)_______________
Extracurricular Activities in High School:
SUPPORTING DOCUMENTS REQUIRED: 1) One page essay as to why you feel you are the best candidate to receive the scholarship. 2) One personal letter of reference 3) One professional letter of reference.
Financial Documents included	ÿ 1040 Tax Return		ÿ Others
Please check your household income: ÿ Below $15,000						Number of people in your household
References
Name	Relationship		Phone Number		Address
I certify that the information contained in this application is true. Applicant’s Signature__________________________________________Date_________________________