KAVANSA B. SMITH MEMORIAL SCHOLARSHIP PROGRAM

UPSILON NU SCHOLARSHIP AND SOCIAL ACTION FOUNDATION, INC.
APPLICATION FOR SCHOLARSHIP AWARD
(Please type or print legibly in ink)
INSTRUCTIONS: The student must complete Sections I and II of this application, secure the parent/guardian’s signature, and give it to his/her guidance counselor to complete Section III. Two references must also be provided to the guidance counselor. The counselor should mail the application, references, an official copy of the student’s academic record that includes the first semester grades and all other required attachments to the address indicated at the bottom of the application. Incomplete, late, or illegible applications will not be considered. We will not contact you if you submit an incomplete or late application.

I. STUDENT INFORMATION

Name / Telephone
Address / City & Zip Code
E-mail address
High School
List Scholastic Recognitions/Honors/Awards Received:
List extra-curricular activities in which you participate including information of offices held or recognitions received:
List community activities in which you participate including information of offices held or recognitions received:
List any special interests and/or hobbies you have:

On a separate sheet, attach an essay of at least 200 words detailing your plans for the future, any special circumstances that may affect your pursuit of a higher education, and your reasons for applying for this particular scholarship.

Name and Location of the College/University You Plan to Attend (if you are considering more than one, please list all you are considering and indicate your first and second choices and those that have offered you enrollment):
Total anticipated tuition and fees for the year:
Amount of financial aid needed to attend for one year:
Have you applied for federal, state, or college based financial aid? Yes No
If no, please explain:
Are you eligible for such funding? Yes No
Please attach a copy of documentation (FAFSA Student Aid Report or other document)showing your eligibility or non-eligibility. If you are not eligible, please explain.

II.FAMILY INFORMATION

(Note: If the student is in foster care or under the care of a guardian, please so indicate and substitute the appropriate information.)
Father’s Name: / Mother’s Name:
Father’s Occupation: / Mother’s Occupation:
Father’s Annual Income: / Mother’s Annual Income:
Total Household Income:
Number of other children in the household
Ages of other children in the household
Number of children presently attending college
Amount of family contribution to college education
Additional comments if desired or necessary to establish your level of need or to explain any extenuating circumstances that may exist to negatively affect your college aspirations:

CERTIFICATION

Weacknowledge that the information contained herein is true and correct to the best of our knowledge. We understand that the discovery of any inaccuracy or false information may result in the committee’s refusal to consider this application.

Date / Student’s Signature
Date / Parent/Guardian’s Signature

III.COUNSELOR’S INFORMATION

(Please attach an official copy of the student’s transcript and references prior to mailing.)
Student’s Current GPA / Class Rank
Student’s latest SAT or ACT Scores: / Verbal Math Essay
Other Appropriate Scholastic or Testing Information Not Included on the Student’s Official Transcript:

CERTIFICATION

I certify that the information contained hereon is true and correct to the best of my knowledge. I understand that the discovery of any inaccuracy or false information may result in the committee’s refusal to consider this application.

Date / Counselor’s Signature
Printed Name

Please return this application and supporting documentation no later than April 23, 2017to:

UPSILON NU SCHOLARSHIP AND SOCIAL ACTION FOUNDATION, INC.

ATTENTION: SCHOLARSHIP COMMITTEE

Po Box 27955 Richmond, VA 23261

Only completed applications postmarked by the deadline will considered.