Central California Alliance

PERSONAL INFORMATION

Name:

Street Address:

City:     State:     Zip Code:

Phone Number:

Email Address:
ť email privacy policy

Current Education Level:
High School Senior     Obtained GED     Undergraduate

Status Next School Year:
Freshman     Sophomore     Junior     Senior     Other

Area of Study or Declared Major:

COLLEGE INFORMATION

School Name:

Mailing Address:

City:     State:     Zip Code:

Phone Number:

ACTIVITIES / INVOLVEMENT

List all the community and school activities in which you have participated.
(Indicate N/A if none.)

List all the GLBT+ activities in which you have participated.
(Indicate N/A if none.)

List Central California Alliance activities in which you have participated.
(Or just tell us what you know about CCA.)

WORK EXPERIENCE

Employer	Phone	How Long?	Position
		to
		to
		to
		to

OBJECTIVES

Please make a brief statement of your plans as they relate to your
educational and career objectives.

FINANCIAL STATEMENT

Will you be receiving other scholarship, grants or need-based loans toward
your education? If so, please indicate the dollar amounts.
(Indicate N/A if none.)

Are there any extenuating circumstances that make financing your education
difficult? Please explain. (Indicate N/A if none.)

TRANSCRIPT

If you are a graduating high school senior, you must include a high school
transcript with this application. If you hold a General Equivalency Diploma,
please include a copy of certification. If you are now enrolled as a college
student, please submit your most recent college transcript.

OTHER CONSIDERATIONS

Please indicate any other circumstances you would like the scholarship
committee to consider when evaluating you application.
(Indicate N/A if none.)

CERTIFICATION & SUBMISSION

By checking here I electronically sign my application and I certify that the information
on this application is true and correct to the best of my knowledge.

Please enter the word shown above for security: