Scholarship Form

Scholarship Application Form

(Please Print; all fields must be filled in)

Section 1: Applicant Personal Information

Name: ____________________________ Home Phone:______________ Cell Phone:______________

Email :_______________________________ (required)

Present Address:

___________________________________________________________________________________

street apt number city state zip code

Number of Years at this Address: ________

Please Provide Prior Address below if at Present Address less than 3 Years

Prior Address:

________________________________________________________________________________________

street apt number city state zip code

High School Attended: ____________________________ Expected Graduation Date _____________

GPA from Transcript * _____ Third Quarter report card – attach copy

*an official transcript must accompany this form

Residency / Citizenship Status: _________________________ Social Security No: ______________________

Section 2: Contact Information for Individual Submitting Application

Name: ____________________________ Home Phone:______________ Cell Phone:______________

Home Address:___________________________________________________________________________________

street apt number city state zip code

Email :_______________________________ (required)

Section 3: CIE Sponsor Contact Information

Name: ____________________________ Home Phone:______________ Cell Phone:______________

Home Address:___________________________________________________________________________________

street apt number city state zip code

Email :_______________________________ (required)

Section 4: Basis for Request for Financial Assistance

Prior Year’s Gross Income (parents’): $___________

Prior Year’s Gross Income (student’s): $___________

• I have submitted a FAFSA for the upcoming academic school year: ______ Yes ______No

* a completed FAFSA print out must accompany this application.

• Funds for college saved by you:______________________________________________

• Funds for college saved by others:____________________________________________

• Scholarships or grants from other institutions (Please list these, also indicate if it is a one time scholarship/grant or a repeating scholarship/grant):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Section 5: Certification

Applicant certifies the information provided above is accurate to the best of his/her knowledge.

Signature of Applicant: _____________________________________ Date:________________

(Parent’s signature required, if applicant is not 18 years or older)