You are on page 1of 2

SCHOLARSHIP APPLICATION

I. APPLICATION INFORMATION Social Security Number: _____-_____-_______

Phone: ( ) ______________--__________

Fax: ( ) ______________--__________

Email: ________________________________

Name: __________________________________________________________________________________
Last (Family Name) First MI Maiden

Mailing Address: __________________________________________________________________________


P.O. Box City State Zip

Village: ________________________________ Phone: ___________________________________________

I am applying as: Freshmen Sophomore Junior Senior

Citizenship: U.S. Citizen/National


Non U.S. Citizen/National: (Country of Citizenship _______________________________)

Sex: Female Male

Birthdate: _______/ ______/ _______ Place of Birth: ______________________________


Mo Day Yr

II. PARENT/LEGAL GUARDIAN INFORMATION

Father's Full Name: _____________________________ Mother's Full Name: ____________________________

Place of Birth: _________________________________ Place of Birth: __________________________________

Citizenship: U.S. Citizen/National U.S. Citizen/National


Non U.S. Citizen/National Non U.S. Citizen/National
Country of Citizenship: _________________________ Country of Citizenship: _________________________

Education: Highest grade/degree completed ________ Highest grade/degree completed _________________

Employer: ____________________________________ Employer: ___________________________________

Annual Salary: $ _______________________________ Annual Salary: $ _______________________________

Years at current home address: 1-5 6-10 v 11-15 16-20 20+


III. ACADEMIC INFORMATION

High School
Name of High School: From:(Mo./Yr) To:(Mo/Yr) Graduation date

________________________________________________________________________________________________

________________________________________________________________________________________________

COLLEGE/UNIVERSITY ATTENDED
Name of School: From(Mo/Yr) To:(mo/yr) Graduation Date

__________________________________________________________________________________________________

__________________________________________________________________________________________________

IV. WORK EXPERIENCE

Employer: _______________________________________________________ Full Time Part Time

Address: ___________________________ Phone: ______________________ How long at present job: ____________

V. PROGRAM INFORMATION

Which program are you applying for ? (check one) ASCC(AA) Undergraduate (BA)
Cumulative Grade Point Average : ____________ High School __________ ___ ASCC
Name and Address of Colleges and Universities :
1._______________________________________________________________________________________________
2________________________________________________________________________________________________
3.________________________________________________________________________________________________

Letter of acceptance : Yes No Pending

Intended Major:___________________________________________________________________________________
I HEREBY CERTIFY THAT THE INFORMATION GIVEN IN THIS APPLICATION IS COMPLETE AND CORRECT TO THE BEST OF MY KNOWLEDGE .
I AGREE AND ACCEPT THAT ANY FALSE STATEMENT(S)OR MISREPRESENTATION MAY RESULT IN DISQUALIFICATION AND/OR
INELIGIBILITY TO RECIEVE THE SCHOLARSHIPAWARD.

RECIEPIENTS OF AMERICAN SAMOA GOVERNMENT (ASG) SCHOLARSHIP AWARDS ARE INELIGIBLE TO RECEIVE MCDONALD'S
SCHOLARSHIP AWARD.

I ACKNOWLEDGE THE APPLICATION IS SPECIFICALLY LIMITED TO THE PROVISION OF FINANCIAL ASSISTANCE BY THE GRANTING OF A
SCHOLARSHIP AND NEITHER THE SCHOLARSHIP COMMITTED NOR MCDONALD'S HAS ANY OTHER OBLIGATION OR RESPONSIBILITY
WHATSOEVER TO ME.

_____________________________________________________________________ ___________________________
STUDENT SIGNATURE DATE