Scholarship Application Form

ACRES Scholarship Application Form
(Please type or print)

___________________________________________________		___________________________
Last Name First Initial		Date of Application
___________________________________________________		___________________________
Current address (Street, City, State & Zip)		Phone #
___________________________________________________		___________________________
Permanent address (Street, City, State & Zip)		Phone #
___________________________________________________		___________________________
E-mail address		Social Security Number

U.S. Citizen	(Circle)	Yes	No
Ethnic Origin	(Optional)	______	Native American	______	Hispanic	______	Black
		______	Asian/Pacific Islander	______	Caucasian	______	Other

Highest degree obtained (major, date, name of institution): ____________________________________________

_____________________________________________________________________________________________

List current certifications: ______________________________________________________________________

_____________________________________________________________________________________________

Current Employer: ____________________________________________________________________________

Position: ___________________________________________________________________________________

Previous Related Work Experiences: _____________________________________________________________

____________________________________________________________________________________________

_____________________________________________________________________________________________

Institution at which scholarship will be used: _______________________________________________________

I hereby certify that the information contained in this application and the statements attached are true and correct to the best of my knowledge. I authorize the release of my grade transcripts and the extent of my financial need to interested donors of scholarships who request this information.

____________________________________________________	_________________________
Signature of Applicant	Date

Applications must be received by February 15th.

Please return completed scholarship form, two letters of recommendation and your essay in a single envelop to:
ACRES Scholarship
C/O Dave Forbush, Ph.D.
Utah State University
Department of Special Education
Old Main Hill
Logan, Utah 84322-2865

Questions? Contact David Forbush Ph.D.
Phone: (435)-797-0697
E-mail: davidf@cc.usu.edu