Please print in ink or type:
Name___________________________Soc. Sec. No.____________ Ethnicity _______________

Address ________________________________________________D.O.B.___________

City ________________ State ________ Zip ____________

Telephone: (home) ________________ (work)_______________ (relative) _________________

Have you met with a CONNTAC-EOC counselor? Yes ____ No ____ If yes, when?_____________

If yes, please provide the counselor's name or site location _____________________________

List schools attended (high school/college): _________________________________________
Year of graduation or did you graduate?_____________________
Anticipated graduation date___________________
Name of school __________________________ Yes ____ No __________________________

Address ______________________________City _________________ State _____ Zip ______

Have you taken the SAT? ____ If yes, what were your scores? M _____ V_____

Do you plan to take the SAT again? ____ If so, when? ________________________

Will a transcript be submitted with this application? Yes ____ No ____
If yes, from which institution(s)? _____________________________________________

* Note: a transcript must be submitted only if you have attended a high school, accredited college or  accredited vocational school within the last two years.

List all extracurricular activities:

Letter of recommendation: submit one (1) letter of recommendation from someone who knows your academic and/or professional work. Letters from relatives and friends or not acceptable.

Statement of intent: (required of all applicants)

On a separate sheet please tell us about your future educational and career goals. This statement should be no more than 250 typewritten (or legibly written) words. Specifically explain how the CONNTAC-EOC program has helped you with your education and career goals. The statement should also briefly state the institution you are presently or will be attending for the upcoming year; the degree program you are pursuing; highlight any extracurricular activities you have participated in and describe any specific obstacles you have overcome in your pursuit of postsecondary education.  

List colleges / postsecondary institutions to which you are applying:
Have you been accepted? For which term?
1.  Name of school __________________________ Yes ____ No _________________________

Address __________________________ City ____________________ State _____ Zip ________

2.  Name Of School __________________________ Yes ____ No _________________________

Address ________________________City _____________________ State _____ Zip _________

3.  Name Of School _________________________ Yes ____ No __________________________

Address _________________________ City ___________________ State _____ Zip _________

Financial information:
Please submit a copy of one of the forms listed below as verification of income and answer the questions that follow:

A. Parent/guardian's recent income tax form, Or

B. Your own income tax return if you are an adult or an emancipated minor, Or

C. A letter or budget sheet stating the total amount of benefits paid to you by state AFDC, Social Security, VA, etc. Or

D. A statement that you had no income due to incarceration. This statement must come from an official or representative of the institution you were incarcerated, Or

E. A signed statement that someone else supported you. This person's income information is required.

1. Did you apply for federal assistance (i.e. Pell Grant)? Yes ____ No ____
If no, why not? __________If yes, amount received __________ Pending _____ Turned down ____

2. Did you receive any financial assistance from the college you plan to attend?
Yes ____ No____ If no, why not? ___________________________________________________

3. Have you ever applied for a CONNTAC, Inc. Scholarship before? Yes ____ No ____
If yes, did you receive it? ____ If so, when? __________________________

Statement of acceptance and release of information

We (I) fully understand that if for any reason the applicant is unable to attend the institution(s) for the semester in which the scholarship is given, We (I) shall return, forthwith, the scholarship awarded to CONNTAC, Inc. We (I) certify that all information contained in this application is complete and accurate to the best of my knowledge. We (I) authorize CONNTAC to obtain any information required from the Registrar and Financial Aid offices of the school the applicant is attending or have attended.

Signature of applicant _________________________________Date ____________________

Signature of parent/guardian (if applicable) ________________________Date _____________

All information is confidential and will be shared only with appropriate officials of CONNTAC, Inc. and members of the CONNTAC, Inc. Selection Committee.

Sponsored by the United States Department of Education