Peralta Colleges Foundation

Student’s NameStudent’s ID #

Date of Application: ____ / ___ / ______Applying for: ______

(Name of one (1) scholarship ONLY)

Master Scholarship Application

Please complete the entire application. Incomplete applications will not be considered. A separate application must be completed for each scholarship administered by the Peralta CollegesFoundation. Please attach your unofficial transcripts and 500 word essay to this application. Make sure your name and student ID number appear on the top of pages 2 - 4.Page 3 (SECTION III: BIOGRAPHICAL DATA & SEPARATE 500 WORD ESSAY)must be typed using Microsoft Word program.A Microsoft Word version of the master scholarship application is located on our website Pages 1, 2 & 4 can be completed by printing legibly (blue or black ink) and/or typed using the master scholarship application on our website. Data not applicable should be noted as N/A. Information provided is strictly confidential.

SECTION I: PERSONAL DATA

Name: ______

LastFirstMiddle

Permanent Address: ______

Complete Street Address

______

CityStateZip Code

Home Phone Number: ______Cell Phone Number: ______

Email Address: ______

Date of Birth: ______/______/______Gender:  M  F US Citizen?  YES  NO

Social Security Number: ______- ____ - ______Student ID Number: ______

SECTION II: EDUCATIONAL RECORDS & GOALS

HS Diploma  YES  NO

High School ______, ______Graduation Date: ______/ ______

Graduated and/or Recently Attended CityMO YR

Peralta Campus Currently Attending:

LaneyCollege

Number of Units Completed: ______Units Enrolled In Current Semester: ______

MerrittCollege

Number of Units Completed: ______Units Enrolled In Current Semester: ______

College of Alameda

Number of Units Completed: ______Units Enrolled In Current Semester: ______

BerkeleyCityCollege

Number of Units Completed: ______Units Enrolled In Current Semester: ______

(UNOFFICIAL TRANSCRIPT

Grand Total Units Completed: ______Cumulative GPA: ______ATTACHMENT REQUIRED)

Have you ever attended another College or University?  YES  NOIf Yes, please list below:

University/College Name: ______Units Completed: ______GPA: ______

Transferring to 4-Year University:  YES  NOIf Yes, please list below:

University/College Name: ______

Type of Degree:  AA  AS  BA  BS  Certificate of Achievement

Major: ______(EXPECTED) Year of Completion: ______

Cert. of Achievement: ______(EXPECTED) Year of Completion: ______

SECTION III: BIOGRAPHICAL DATA & SEPARATE 500 WORD ESSAY

Please answer all three (3) questions below on a separate sheet, typed, single-spaced,

using 12-point font Microsoft Word program:

Question #1: Work experience while attending college?

(Please provide employer, position held, employment dates, and hours worked per week)

Question #2: Extra-Curricular Activities?

(Please include exact dates and description of activities)

Question #3: Any awards, honors or recognition received?

(Please list all acknowledgements and exact dates)

SEPARATE 500 WORD ESSAY:

In 500 words or less, please briefly describe what qualifications you have that makes you deserving of this scholarship. Also, please tell us about your current AND future academic, career, and personal goals. Essay must be typed, single-spaced, on a separate sheet,

using 12-point font.

SECTION IV: FINANCIAL INFORMATION

To be completed by the Financial Aid Office

Note: Please give this pageto the Financial Aid Office, which will complete the form and contact you when it is ready to be picked up. You must have this form completed before you can submit your scholarship application. Please make an appointment with the Financial Aid Office at least two weeks in advance to have this form completed

Has the student received financial aid at any of the Peralta Colleges? Yes _____No _____

If Yes, please list:

Grant: ______

Amount Received: ______Year: ______PeraltaCollege: ______

Grant: ______

Amount Received: ______Year: ______PeraltaCollege: ______

Grant: ______

Amount Received: ______Year: ______PeraltaCollege: ______

All Other aid______

Marital Status: Single _____ Married _____ Separated _____ Divorced _____

Number in Household: ______

Student is: Independent:______Dependent:_____

Student Cost of Attendance: ______

Remaining Need: ______

The Financial Aid Office must be notified when a student receives a scholarship award.

FAO Certification:

______

Name Title Date

Under the California Dream Act (AB 130) students attending a Peralta college who are exempt from paying nonresident tuition under AB 540 are eligible to receive scholarships funded by private donations and administered through the Peralta Colleges Foundation. If the scholarship(s) for which you are applying requires you to demonstrate financial need, you have several options:

Provide your most recent tax return or other income verification.
A letter of recommendation from someone who can also confirm your financial need.
Provide proof that your currently receive AFDC (Aid to Families with Dependent Children), TANF (Temporary Assistance to Needy Families), SSI/SSP (Supplemental Security Income), or General Relief. Students must show proof (i.e., copy of a CA-7 with current or last month’s date, agency verification, etc.)
Complete the Free Application for Federal Financial Aid (FAFSA), if you are eligible to do so.

*** FOR INTERNATIONAL STUDENTS ONLY ***

THIS FORM MUST BE SIGNED OFF BY

FRIDAY, FEBRUARY 15, 2013. YOU CAN NOT APPLY FOR PERALTA SCHOLARSHIPS UNLESS THIS FORM IS SIGNED OFF BY A DESIGNATED SCHOOL OFFICIAL.

SECTION V: INTERNATIONAL ECONOMIC HARDSHIP VERIFICATION

To be completed by the International District Office

IMPORTANT: F-1 international students can prove economic need by applying for economic hardship verification. You may apply for economic hardship through the International Students office located at the Peralta Community College District Office. Please give this page to a Designated School Official (DSO) at the International Students Office for verification of application and date/signature. A DSO will contact you when it is ready to be picked up. You must have this form completed before you can submit your scholarship application. Please make an appointment with the International District Office as soon as possible to havea DSO enter your economic hardship request through the SEVIS (Student Exchange and Visitor Information System). Once entered, your application must be approved by the USCIS(United States Citizens and Immigration Services) before being considered for a scholarship.If approved, you must submit the approval letter to the DSO. They will then contact our office to confirm that you have been approved.

PLEASE NOTE: If you are chosen as a recipient (winner) of a scholarship you’ve applied for, and you have NOT been approved for economic hardship, your application will be denied and you will be considered ineligible to receive your award.

The International District Office must be sign and date this portion.

International Economic Hardship Certification:

______/ ______/ ______

DESIGNATED SCHOOL OFFICIAL MO DAY YEAR

______/ ______/ ______

MODAY YEAR

Application Date of Economic Hardship

ALMOST FINISHED! LAST STEP!

Did you remember to…?

Indicate which scholarship for which you are applying for? Each scholarship requires A SEPARATE APPLICATION.

Fully complete and sign your application form?

Include 2 letters of recommendations and/or references? IF REQUIRED AS PART OF SCHOLARSHIP CRITERIA.

Include an unofficial copy of required transcripts?

Include your Biographical Data & Separate 500 Word Essay?

Include Page 4 of the Master Scholarship Application COMPLETED AND SIGNED OFF BY AN OFFCIAL FINANCIAL AID OFFICER?

Remember, only fully-completed scholarship applications – those that include the financial information form on the following page -- will be considered for a scholarship. The Peralta Colleges Foundation will not review any submitted scholarship application. It is the applicant’s responsibility to make sure the application is fully completed and in compliance with the scholarship criteria.

Student’s Certification:

I certify that the information contained on this application is true and correct to the best of my knowledge. I understand that willful omission or falsification may disqualify me as a scholarship recipient.

Signature: ______Date: ______/ _____ / ______

MO DAY YEAR

Revised 09.17.2012 PCF Master Scholarship Application Page 1 of 6