Ila

Educational Scholarship Application

Personal Data

NAME: ______

Last NameFirst NameMiddleSuffix

Date of Birth: _____/_____/_____ Sex: _____Female_____Male

Month Day Year

Citizenship: ______

Permanent Home address: ______

Number and Street nameCity/TownState

Mailing address (if different than Permanent Home address): ______

Number and Street nameCity/TownState

Home Phone: ______Cell Phone: ______Email: ______

Family

Household

With whom do you make your permanent home?

_____Mother _____Father _____Both (Mother & Father) _____Legal GuardianOther ______

Please specify

_____# of brothers and sisters_____# of people in household

Please fill out all applicable information with the information below. If, for some reason (eg. Deceased, you are unable to provide the information of one of your parents, leave section blank.

Mother

Mother’s Name: ______

Last NameFirst NameMiddle

Home Phone: ______Cell Phone: ______Email: ______

Occupation: ______Name of employer: ______

Yearly Gross Income: $______

Father

Father’s Name: ______

Last NameFirst NameMiddle

Home Phone: ______Cell Phone: ______Email: ______

Occupation: ______Name of employer: ______

Yearly Gross Income: $______

Guardian

Guardian’s Name: ______

Last NameFirst NameMiddle

Home Phone: ______Cell Phone: ______Email: ______

Occupation: ______Name of employer: ______

Yearly Gross Income: $______

Educational Particulars

Name of current or most recent High School/College: ______

(circle one)

Entry date: _____/_____/_____Anticipated Graduation Date: _____/_____/_____

Month Day Year Month Day Year

Address of High School/College: ______

(circle one)

Principal’s/Deans Name: ______

(circle one)

Business Phone: ______Fax #: ______Email: ______

Program of Study: ______

Current CGPA: ______

Current Extracurricular activities: ______

Signature

I certify that all information submitted in the application process – including the application, the personal essay, and any other supporting materials – is my own work, true, and honestly presented. I understand that my application may be dismissed should the information be false. I also certify that all necessary documents are attached:

  1. Completed Application
  2. Scanned copies of any other letters of award
  3. Essay as outlined in the instructions
  4. Scanned copy of Transcript
  5. Proof of Enrollment/Acceptance (Copy must be provided prior to disbursement of award)

Signature: ______Date: _____/_____/_____

Month Day Year

For Official Use Only

Date of Application Received: ______

Checklist of Documents:

  • Completed Application
  • Copy of any other letters of award
  • Essay
  • Official Transcript
  • Proof of Enrollment/Acceptance

1

Application and supporting documents MUST be emailed to:

Deadline of Application for 2011-2012: April 16, 2011