Scholarship Application Form for Part-Time Students
Name: ___________________________ SSN: _______________________
Address:
_______________________________________________________
Street
City
Zip
Home Number: __________________ Work Number: _________________
Educational Data
High School
Attended _______________ Date of Graduation or GED ________
Cumulative HS GPA _______ Cumulative Chipola GPA, If Applicable ________
Previous
Colleges/Universities Attended and Dates of Attendance:
__________________________________________________________________
__________________________________________________________________
Intended Major at Chipola ______________________________________________
Briefly State Your Educational Goals ___________________________________
__________________________________________________________________
Scholarship
Funds Are Requested For The Following:
(Check all that apply)
____
Books and fees for fee waived course.
(Not to exceed $100.00
per Semester)
____
Tuition and fees for a course whose fee is not waived.
(Not to exceed $150.00
per semester)
____
Books and fees for a course whose fee is not waived.
(Not to exceed $100.00
per semester)
I hereby authorize Chipola College to release information from my academic record to the FACC/Chipola
Scholarship Committee for determining scholarship awards.
_____________________________________
_______________________
Signature of
Applicant
Date
Last Revised: May 31, 2005