Scholarship Application

SCHOLARSHIP APPLICATION

Personal Information
Name*
Prefix First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
D.O.B.*
MM slash DD slash YYYY
SSN*
Marital Status*
School Information
Name of Institution*
Institution Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Degree or Certificate Sought*
Academic Information
HS Grad Date*
MM slash DD slash YYYY
HS GPA*
SAT Reading Score*
SAT Math Score*
SAT Writing Score*
List all non-credit courses you have taken:
Please describe your relationship with Blueprint 58:

Financial Data
Enter estimated college costs and expected funds figures below. Check college aid offices or catalogs for costs. If the college choice is not definite, enter costs of your most likely choice; send revised information as soon as you know it. Comment on all unusual factors on a separate page if necessary.
Estimated Cost
Tuition and Fees*
Books and Supplies*
Room and Board*
Transportation*
Personal*
Other Costs (Explain)*
Total Estimated Costs*
(Explain unusual costs, such as special equipment, costly transportation, etc.)
Expected Fund Sources
Parent Contribution*
Student Contribution*
Federal Loans*
Federal Grants*
State Loans*
State Grants*
College:*
Other:*
Total Funds Applied For:*
Include all aid you might receive; give title, amount and status (pending or approved).
*Enter what you and your mother/father expect to pay toward college costs. Explain if the parent contribution is low or if there is no student contribution.
Additional Financial Information
Provide any additional information regarding your need for financial aid:*
Give any additional information that you think might be useful to the selection committee in considering your application. Use additional sheets if necessary:*

Read, Sign, & Date
Certification: All of the information provided by me on this form is true and complete to the best of my knowledge. If asked, I agree to give proof of the information that I have given on this form. I realize that the committee examining my application may request proof of my need for financial assistance. I also realize that if I do not give proof when asked that my application for assistance may be denied.
Signature
Today's Date*
MM slash DD slash YYYY
I UNDERSTAND that selection decisions by BLUEPRINT 58, INC. are final and are not subject to appeal.
Signature
Today's Date*
MM slash DD slash YYYY