ADDRESS:      

CITY:              

STATE:           

ZIP CODE:     

SUMMER ADDRESS IF DIFFERENT FROM ABOVE:

DATE OF BIRTH:  

Have you received MCB Scholarships previously? Yes/No.  If yes, please indicate year awarded and amount received:         

U.S. Citizen? Yes or No. If no, give alien registration number:  

Describe the cause and degree of visual impairment:  Describe the cause and degree of visual impairment: 

1.   School in which you are presently enrolled:  Name of School: 

2.   City:    

3.   State:  

4.   Cumulative grade point average (based on a 4.0)  

5.   Major:  

6.   Full or part time:  

7.   Certificate:          

8.   Presently seeking BS, MA, etc.:  

9.   Date degree expected:   

10. If you are entering this school as a freshman or transfer student, proof of acceptance must be included with your application materials.  If you have not been notified of your acceptance as of the date that you are submitting this application, please indicate below the date on which you expect to receive notice from the school.  Date: 

1.  Name of School:  

2.  City:                    

3.  State:                  

4.  Zip Code:           

5.  Dates attended:  

6.  Cumulative grade point average (based on a 4.0) 

A:  ACT: 

1. ACT Date Tested:          

2.  ACT Composite Score:  

B:  SAT:  

1.  SAT Date Tested:           

2.  SAT Composite Score:   

List all full or part-time work experience.  Indicate whether this was summer employment or during the school year.  

List all major outside activities (school, religious, community-etc., sports, organizations of the blind, recreation, etc.).  Include extent to which you have played a leadership role. 

Name:         

Title:            

Address:      

Phone:         

Date:           

Signature: