sch-app

Scholarship Application
Visually Impaired Student
Post-Secondary

PERSONAL DATA:

Name:_______________________________Sex: M___F __
Address:_______________________________________ ZIP:________
Phone: Home ( )____________ Work ( )__________
Social Security #____________D.O.B.__________
Resident? Yes ___ No___

EDUCATIONAL BACKGROUND:

School in Which Presently Enrolled: ________________________
Attending in the Fall: ____________________________________
Degree Presently Seeking: _____________________________
Date Degree Expected: ______________________________________
Major/Career: ___________________________

NOTE: Please attach proof of acceptance from school attending or planning to attend.

WORK EXPERIENCE:

EXTRA-CURRICULAR ACTIVITIES OR SPECIAL INTERESTS;

DESCRIBE THE CAREER THAT YOU HAVE CHOSEN AND WHY YOU HAVE SELECTED IT.

Mail the completed application with the following:

Two letters of recommendation from someone other than a relative
Proof of acceptance of school attending or planning to attend
Proof of visual impairment from an ophthalmologist, optometrist, teacher of the visually impaired, or rehabilitation specialist.

Address to:

Mrs. Jan Jasko