1. Name * First Last 2. Home Address Address Line 1 * Address Line 2 City * State * Zip Code * 3. Father's Name/Occupation 4. Mother's Name/Occupation 5. High School Graduation Date 6. Class Rank 7. GPA * 8. ACT Score 9. Number of Children in Family 10. Number of Children Attending Post-Secondary School 11. List Extra-Curricular Activities, Honor and/or Awards You Received in High School (You may attach additional paper if necessary) Check here if you upload addition files below. Files Uploaded File Upload (for additional extra-curricular activities submitted) Select File(s) PDF Files under 2 MB Only 12. Name of School You Will Attend 13. Reasons for Selecting This School 14. Intended Major 15. When Do You Expect to Complete College? 16. Briefly State Your General Education Plans and Ambitions Financial Information Some description about this section 17. Average Annual Educational Expenses Please provide an average amount expected for a school year. Tuition & Fees $ Room & Board $ Books $ Travel $ Miscellaneous $ Total Average Annual Education Expenses (total all above) $ This form does not total automatically, please enter the total. 18. Annual Financial Resources Expected Parent Contributions $ Student Contribution $ Scholarships $ Grant $ Loans $ Other (Social Security, etc.) $ Total Annual Financial Resources Expected (all above) $ This form does not total automatically, please enter the total. Where Have You Worked in the Summer? 20. Are You Working Now? and Where? 21. Please give any extenuated circumstances impacting your financial need that the Committee should consider. (For example: large debts, grandparents supported by family, serious illness, death in the family, etc.) I DECLARE THAT THE INFORMATION REPORTED ON THIS STATEMENT, TO BE THE BEST OF MY KNOWLEDGE AND BELIEF, IS TRUE AND COMPLETE. Student and Parent Signatures * Clear Both Student & Parent Signatures go in this one box. Date * mm/dd/yy
