Full Name
Social Security #
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Daytime Phone
E-mail
Major
Grade Point Average (GPA)
Date of Birth

For what semester are you applying?
Spring 2010    Summer I & II 2010    Fall 2010

Have you completed the Free Application for Federal Student Aid (FAFSA)?
Yes    No
If No, when will FAFSA be completed?

I certify that the above information is accurate, and I authorize the Scholarship Committee to verify the information I have provided.

_________________________    ______________
Student's signature                   Date

Please fill out, print, and return this page to the above address.