Scholarship Application
To be considered for the National Internet Scholarship, please fill in the information below as completely and accurately as possible.
Student Information
*
First Name
MI
*
Last Name
*
Address 1
Address 2
*
City
*
State
*
Postal Code
Phone
Email Address
*
Race/Ethnicity
African American
Asian
Caucasian
Hispanic
Native American
Other
*
Marital Status
Married
Separated
Divorced
Domestic Partners
Single Parent
Unmarried
*
Residence Status
US Citizen
US Permanent Resident
International Student
*
Major
Academic Records
*
High School
*
City
*
State
*
Cumulative GPA
ACT Score
SAT Score
*
Please list any awards or honors that you have received.
Please list any sports, extracurricular, or community service activities that you have participated in.
References
Name
Title
Phone
Email Address
Name
Title
Phone
Email Address
Name
Title
Phone
Email Address
*
Indicates Response Required