POULSON FAMILY SCHOLARSHIP APPLICATION

I. Personal Data

Name:

Street address :
City:
State
Zip:

Daytime phone number:

Evening phone number: ___________________________________________________

E-mail address:

Social Security Number:

Date of birth:
(day, month, year)

U.S. Citizen?
Yes ( )
No ( )
(If you're filling this out on the computer, you can just delete the incorrect answer.)
If no, give alien registration card number: ______________________________________________________

II. Educational Background

Part A:

1. School in which presently enrolled:
City (in which school is located):
State:

2. Cumulative grade point average (based on a 4.0 scale):

3. Major:
Full or part time?:
Degree presently seeking (BS, MA, etc.):
Date degree expected:

4. Answer this question ONLY if the information is different from that given in questions 1 through 3:
List the school you plan to attend in the fall:
City:
State:
Major:
Full or Part time?:
Degree you plan to seek (BS, MA, etc.):
Date degree expected:
Note: If you are entering this school as a freshman or a transfer student, proof of acceptance must be included with your application.

Part B:

List any other secondary or post secondary schools you have attended (include additional typed sheets if necessary):
Name of school:
City in which it is located:
State in which it is located:
Dates attended from month/year ________________ to month/year
Cumulative grade point average (based on the 4.0 scale):
Major:
Degree or certificate received, if any (high schooldiploma, AA, BA, etc.):

Name of school:
City in which it is located:
State in which it is located:
Dates attended from month/year ________________ to month/year
Cumulative grade point average (based on the 4.0 scale):
Major:
Degree or certificate received, if any (high schooldiploma, AA, BA, etc.):

III. Test Record Information

1. If you are or will be a college freshman, include scores for either or both of the following tests:
A. ACT:
(1) Date tested:
(2) Composite score:
B. SAT:
(1) Date tested:
(2) Composite score:

2. For entering graduate students, (Include scores from any tests such as GRE, GMAT, LSAT, etc.):
Test:
Date tested:
Composite score:

IV. Work Experience

List any full time or part time work experience. Indicate whether this was summer employment or during the school year.
1.
2.
3.
4.
5.

V. Extracurricular Activities

List major activities (school, religious, community--e.g., sports, organizations of the blind, recreation, etc.) Include extent to which you have played a leadership role.
1.
2.
3.
4.
5.
________________________________________