Educational Scholarship Fund Application – Missouri Council of the Blind

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email

Summer address if different from above

Date of Birth (MM/DD/YY)

Are you a U.S. Citizen

Yes
No

If not, give Alien Registration Number

Visual Status (Give cause and degree of visual impairment)

Membership

Member at Large
Non-Member
Affiliate

If an Affiliate member, please list the name of the Affiliate

Have you been awarded an MCB Scholarship prior to this application? If so list, what year and amount awarded.

Educational Background

Name of School you are presently enrolled in:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Cumulative GPA (based on 4.0)

Major

Presently Seeking (BS, BA, MA, etc)

Anticipated Graduation Date

If you are entering this school as a freshman or transfer student, proof of acceptance must be included with your application materials. If you have not been notified of your acceptance, please indicate the date on which you expect to receive notice from the school.

List other secondary or post-secondary schools you attended (include additional typed pages if needed): Name of School, City/State/Zip, Dates Attended, GPA

Test Record Scores (ACT/SAT Composite Score and Date tested)

Work Experience

List all full or part-time work experience. Indicate whether this was summer employment or during the school year:

EXTRACURRICULAR

List all major outside activities (school, religious, community, sports, organizations of the blind, etc.) Include extent to which you have played a leadership role:

Signature of Applicant and Date of Application

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