Last Name _____________________________________________________________
First Name ____________________________ Middle Name_______________________
Preferred Name __________________________________________________________
Mailing Address __________________________________________________________
______________________________________________________________________
Permanent Address (if different than above) ______________________________________________________________________
______________________________________________________________________
County of Residence ______________________________________________________
High School Name ______________________________________________________
Email ______________________________ Home Telephone _____________________
Gender _______________________ Date of Birth _____________________________
Weighted GPA: ____________ Class Rank: __________ of ________ total students
SAT Scores: V ________ M ________ W ________ Combined ________
Intended Major: ___________________________________________________________
School/College you plan to attend this fall: ______________________________________________________________________
(if undecided, please list where you have applied or been accepted) ______________________________________________________________________
______________________________________________________________________
Type of School: ____ 2 year ____ 4 year ____ Graduate ____ Other: ____________________
Year of study this fall: ____ Freshman ____ Sophomore ____ Junior ____ Senior
____ Other: __________________________________________________________
Enrollment Status: ____ Full Time (12+ hours) ____ Part Time (6-11 hours)
____ Other: __________________________________________________________
I certify that the information provided in this application packet is complete and accurate to the best of my knowledge. I understand that falsification of information will result in termination of any scholarship granted. I understand that incomplete applications may not be considered. I certify that I have read the instructions and will comply with all requests for documentation of financial need and academic status. Should I receive a scholarship, I will notify the NCCF of any change of plans, and the NCCF may use my name and likeness in publicity materials relating to the Foundation.
I understand that NCCF scholarships may only be used towards the published cost of attendance at accredited US institutions of higher learning.
Student Signature ________________________________ Date __________________
