Boone County Single Parent Scholarship Reapplication Form

PERSONAL INFORMATION:

Application Date:__________________________      Social Security Number: ________________________

^{(must submit an application for each semester applied.)}

Semester Applying for:   Fall 20_____    Spring 20_____           Summer 20_____

1.      Name: ______________________________________________________________________________

Last                                         First                         Middle                                     

2.      Address: ____________________________________________            Home Phone:________________

         ____________________________________________           Work Phone:________________

            City                                                         State        Zip Code

3.        Circle One:             Single                     Married                  Divorced                Legally Separated                    Widowed

4.      Including yourself, how many individuals are dependent on you for financial support? ______________

5.      List the following information:

6.      Is anyone else sharing your household expenses? (excluding governmental assistance)                   Y     or     N

7.      Do you have any relatives living in the area?                                                       Y     or     N

      Check below the assistance your relatives provide for you and your children.

8.      Do you have medical insurance?                           Y     or      N

9.      Do you own a personal computer?                       Y     or      N

EDUCATIONAL:

10.  Major: ______________________________________  Number of Hours Enrolled: __________________

Anticipated Graduation Date: ____________________

FINANCIAL AID:

1.      Have you applied for Federal Financial Aid?        Y      or       N

2.      Have you received Pell?                                       Y      or       N    

      Complete the following for the academic year for which you are applying:

3.      Number of hours worked while attending school?________________________

4.      Place of employment: ____________________________  Phone: ________________________________

5.      For what types of costs do you anticipate using the Single Parent Scholarship? _____________________________________________________________________________________

FINANCIAL INFORMATION:

Please list all sources of income you are currently receiving in Column A and income you expect to receive during the next 12 months in Column B.

EXPENSES

What are your average “out of pocket” monthly expenses? (Please list dollar amount)

Reapplication form and copy of grades should be returned to: Single Parent Scholarship Committee

                                                                                                            Educational Opportunity Center

____________________________________________                    North Arkansas College

Applicant’s Signature                                                                                                         1515 Pioneer Drive

                                                                                                            Harrison, AR  72601

_____________________________________________________                                            (870)391-3524

Date