Contact

1

2

3

SSN

Sex

MI

First Name

Last Name

CURRENT MAILING ADDRESS 1

PERMANENT MAILING ADDRESS 1

CURRENT MAILING ADDRESS 2

City

State

Zip

Phone

Email

City_2

State_2

Zip_2

PERMANENT MAILING ADDRESS 2

Phone_2

Email_2

Birth Date

Blood Quantum

Tribe

Place of Birth

Permanent Email Address

Currant EmailAddress

Phone Number

Zip_3

State_3

City_3

Name of College University you will attend

Graduation Date

Field of Study

DO Ed D PhD PsyD PharmD

Graduation Date_2

Name and location of high school attended

College GPA on 40 scale

High school GPA on 40 scale

ile_3

Math

ile_2

SAT Verbal

ile

College test scores ACT Composite

Percentile

Raw Score

Other Test Name LSATMCATMATGREetc

to

Dates of Military Service From

Branch of Service

Separated

Widowed

Divorced

Married

Single

Marital Status

Number of dependent children residing with you

AGES 1

AGES 2

YOURE CHILDRENS NAMES 1

YOURE CHILDRENS NAMES 2

List courses and grades in your major field of study Please list high school grades if you are about to enter college Students must

AGES 3

Number of persons in household

COURSE TITLE GRADE 1_3

COURSE TITLE GRADE 2_3

COURSE TITLE GRADE 3_3

COURSE TITLE GRADE 4_3

Explain the relevance of the courses you have taken to your planned career 1

COURSE TITLE GRADE 1_2

COURSE TITLE GRADE 2_2

COURSE TITLE GRADE 3_2

COURSE TITLE GRADE 4_2

COURSE TITLE GRADE 1

COURSE TITLE GRADE 2

COURSE TITLE GRADE 3

COURSE TITLE GRADE 4

Explain the relevance of the courses you have taken to your planned career 2

Explain the relevance of the courses you have taken to your planned career 3

Senior
Yes

Freshman
Yes

Sophomore
Yes

Junior
Yes

Graduate
Yes

Post Graduate
Yes

Class Rank

Listed as dependent yes
Yes

Listed as Dependent No
Yes

AwardsHonors earned in high school andor college 1

AwardsHonors earned in high school and or college 1

AwardsHonors earned in high school andor college 2

MembershipLeadership Roles 1

undefined_2

MembershipLeadership Roles 2

VolunteerCommunity Efforts 1

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VolunteerCommunity Efforts 2

Date

SSN_2

Maiden Name

Last Name_2

First Name_2

Date of Birth

Place of Birth_2

Sex_2

Mothers Maiden Name

Fathers Name

Current Mailing Address

City_4

State_4

Zip_4

Date_2

Tribe_2

Degree of Indian Blood

CensusEnrollment No

Yes or No

Is this US Tribe

Federally recognized

State Recognized

Comments

Date_3

Title

Business Phone No

Student Name

Soc Sec No

Address

Zip_5

State_5

City_5

Summer 20_2

Spring 20

Funding Request For Fall 20

College University

Major

Full or part time

Date_4

College Name

Address_2

Zip_6

State_6

City_6

Tuition and Fees

EFC

BIA

undefined_10

Books and Supplies

Private Scholarships

Tribal Scholarships

Transportation

Grants

Personal

Loans

Other

Work Study

Veterans Benefits

Other (Specify)

Total Resources

Total Expenses

If yes when

Print name of person completing form

Phone No

Title_2

Date_5

SCHOLARSHIP 1

SCHOLARSHIP 2

SCHOLARSHIP 3

SCHOLARSHIP 4

SCHOLARSHIP 5

SCHOLARSHIP 6

SCHOLARSHIP 7

SCHOLARSHIP 8

SCHOLARSHIP 9

SCHOLARSHIP 10

SCHOLARSHIP 11

SCHOLARSHIP 12

SCHOLARSHIP 13

SCHOLARSHIP 14

SCHOLARSHIP 15

SCHOLARSHIP 16

SCHOLARSHIP 17

SCHOLARSHIP 18

SCHOLARSHIP 19

SCHOLARSHIP 20

SCHOLARSHIP 21

SCHOLARSHIP 22

SCHOLARSHIP 23

SCHOLARSHIP 24

SCHOLARSHIP 25

Term Applying Fall
Yes

Term Applying Spring
Yes

Term Applying Summer
Yes

Military Veteran Yes
Yes

Military Veteran No
Yes

Middle Initial

Your Name (required)

Your Email (required)

Subject

Your Message