1. I would like to apply for: *

Merit-based scholarship

Need-based scholarship

Both

2. Student Name *

First Name

Last Name

3. Student Date of Birth *

MM

DD

YYYY

4. Student Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

5. Is the student a U.S. citizen or permanent resident? *

Yes

No

9. Does the student receive financial aid at their current school? *

Yes

No

10. Parent Name *

First Name

Last Name

12. Parent Mobile Phone *

(###)

###

####

13. Parent Address

If different from student

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

14. Total gross family income: (Required for need-based applicants)

Under $200,000

Over $200,000 (please specify your need-based situation)

Parent/Guardian Signature *

First Name

Last Name

Printed Name *

First Name

Last Name

Sign Date: *

MM

DD

YYYY