Last Name: ______________________ First Name: ______________________
MI ___
Maiden: _________________ Social Security Number: ______ - ____ - ______ Date
of Birth ____ / ____ / ____
e-mail address _____________________________________________________
Permanent Address:
Street: ________________________________ City: ________________________ State:
_____
Zip Code: ____________ Telephone: (_____) ______ - ____________
Local Address:
Street: ________________________________ City: ________________________ State:
_____
Zip Code: ____________ Telephone: (_____) ______ - ____________
Enrollment Status:
| ___ New Freshman | ___ Transfer | ___ Re-Entry | ___ Currently Enrolled |
Classification:
| ___ Freshman | ___ Sophomore | ___ Junior | ___ Senior |
This application for scholarships is for the _________________ academic school year
Scores:
| ACT: ______ | High School GPA: ______ |
| SAT: ______ | College GPA (if applicable): ______ |
| Intended Major at Northwestern_______________________________________________ | |
| Hish School Graduated From: ________________________________________________ | |
| Date Graduated: __________________________________________________________ | |
Is either parent or guardian a Northwestern State University Graduate? _______
If yes:
Names: ______________________________________________________
Street: ________________________________ City: ________________________ State:
_____
Zip Code: ____________ Telephone: (_____) ______ - ____________ Year Graduated:
_______
List below any honors you have received. (Include academic, extracurricular, athletic, community service, etc.)
List Extracurricular Activities (Include participation in community activities as well as...
If there is any further information that you feel would be helpful to Northwestern State University in considering you for NSU Foundation scholarships, please use the following space to explain.
I certify that the information submitted is true and complete to the best of my knowledge. __________________________