Scholarship Application

Name:  _________________________________________________________________

Address: __________________________________State: _________  ZIP ___________

Home Phone: (______) _____- _________    Work Phone (______) ______- __________

Social Security Number ______-_______-______   Date of birth ______/______/______

School _______________________    Program of Study __________________________

GPA if currently a student ________    Are you  US citizen YES  /  NO

How much financial aid are currently receiving? $ __________

Estimated costs of Schooling? $_________         Are you a veteran? YES  /  NO

Are you supporting Yourself? YES  /  NO         Monthly Income? $___________

Please provide the following information along with this application. All information is required in order for the application to be valid. Deadline for submitting is August 31st.

·          Complete education history, starting with High School. Please include name of institution and address. Include major of study and whether you received a degree or certificate.

·          If still in school please provide transcripts.

·          Complete work history, including dates of employment, job title, and a brief description of your job duties.

·          Volunteer activities you are or have been involved with.

·          List of awards, citations or acknowledgments.

·          Brief autobiography.

·          Short essay on why you feel you deserve this scholarship and how you became interested in the field of Biomedical or Clinical technologies.

·          At least one Letter of Recommendation. ( see Attached Sheet)

Signature of applicant________________________________       Date ____/_____/______