2017 High School Scholarship Program for North Carolina

Application Required

Please complete all information on this form

Student Data Form Personal Information
Recipient First Name	Recipient Middle Name	Recipient Last Name
Last Four Digits of Recipient’s Social Security Number
Home Street Address
City	State	Zip Code
NC
Telephone # (Include Area Code)
Gender: (Male/Female)
Race/Ethnicity:
GPA - Weighted
GPA - Unweighted
Permanent E-mail
Has the student submitted their FAFSA?
Demonstrated Financial Need?
If parent/ guardian works in the public sector field, which area?
Intended Major?
University Information
University Attending (Attach Acceptance Letter)
High School Information
High School Name	Is School an Early College or Cooperative Innovative School? (Check Box if yes)
High School Street Address
City	State	Zip Code
NC
Contact Person for High School
Contact Person E-mail
Date of Awards Ceremony	Time of Awards Ceremony
Location of Awards Ceremony

Please Note: Student data sheet must be returned as a Word document only. Please email directly to secufoundation@ncsecu.org

Remaining application pieces can be submitted as a PDF and emailed back to secufoundation@ncsecu.org as one document:

Brief Statement from Student of Awards/Accomplishments & Short Bio (to be released to local media)

Student Photo and completed Essay

Acceptance Letter from University

Signed Media Consent Form (Signed by Recipient and Parent/Guardian)

Brief Statement from Selection Committee that must be signed by all members of the Committee to verify recipient and alternate. Please note, Selection Committee must have three or more members.