EmailMe Form - Noir Knowledge Scholarship Application

Name

First Last

Email

Social Security Number

Phone

### - ### - ####

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Emergency Contact

Name

First Last

Relationship

Phone

### - ### - ####

Email

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Universities that are recipients of federal dollars are required by the Federal government to solicit certain demographic information to meet federal reporting requirements. Applications are requested to provide the following information voluntarily. This information will not be utilized in a discriminatory manner.

Nation of Citizenship

Race / National Origin

Native Language

Religion

Gender

Male

Female

Are you a veteran of the U.S. Military?

Yes

No

Date of Birth

MM / DD / YYYY

This application is for enrollment as:

Freshman (First time in College)

Undergraduate Transfer

2nd Bachelor's Degree

Former Student Returning (FSR)

What is your planned major?

Please indicate your housing preference:

On-campus

Off-campus

If your records have been expunged pursuant to applicable law, you are not required to answer yes to the following questions. If you are unsure whether to answer yes, we strongly suggest that you answer yes and fully disclose all incidents to avoid any risk of disciplinary action or revocation of your offer of admission.

Are you currently or have you ever been charged with or subject to disciplinary action for scholastic or any other type of misconduct at any educational institution?

Yes

No

If yes, please explain.

Have you ever been charged with a violation of the law which resulted in, or if still pending could result in, probation, community service, a jail sentence, or the revocation or suspension of your driver’s license (including traffic violations which resulted in a fine of $200 or more?)

Yes

No

If yes, please explain.

High School Information

High School Name

6 Digit High School CEEB Code

Graduation Date

MM / DD / YYYY

Or enter year of GED

High School Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

High School Web Site

High School Phone

### - ### - ####

Please provide the names of people in your immediate family who have attended the University.

1. Name

First Last

Relationship

2. Name

First Last

Relationship

Extracurricular, Personal and Volunteer Activities

Talents and Awards:

List each, a description, the level, and number of years of involvement.

Extracurricular Activities:

List your organizations, position, description of the activity, and hours per week of involvement.

Employment:

List the job, your title, description, hours per week, and dates of employment.

Community Service Work:

List the type of work, your role, and hours per week of involvement.

Attach additional Word, Powerpoint, PDF or text document if necessary.

Parent Information

The information requested below is optional, but it may assist in the review of your admission. You are strongly encouraged to complete this section.

Father or Legal Guardian Occupation

Father or Legal Guardian Education

Mother or Legal Guardian Occupation

Mother or Legal Guardian Education

Please indicate your family’s gross income for the most recent tax year. Include both taxed and untaxed income.

Do you have family obligations that keep you from participating in extracurricular activities?

No

Yes, I have to work to supplement family income.

Yes, I provide primary care for family member(s).

Other...

If yes or other, please describe:

I understand that this application is for a scholarship only for the amount indicated. I agree that I am bound by regulations concerning application deadlines and admission requirements. I agree to the release of any transcripts and test scores to this institution, including any SAT, Achievement Test, and ACT score reports.

I certify that this information is complete and accurate.

Do you understand and agree to the terms listed above?

Yes, I understand and agree to the terms listed above.