First name: Middle name/initial: Last name: Home phone: Cell phone: Date of birth: ) - ) - / Email address: Gender: Female Male Ethnic Heritage of… Mother: Maternal Grandmother: Maternal Grandfather: Father: Paternal Grandmother: Paternal Grandfather: Permanent Residence Address (Number & Street): Apartment/Suite: City: State: Zip Code: County (not Country): Mailing Address (if different from above) Address (Number & Street): Apartment/Suite: City: State: Zip/Postal Code: Parent or Guardian Information First name: Middle name/initial: Last name: Relation to applicant: Telephone: Email address: ) - Address (if different from above): Will you be the first in your immediate family (parents and siblings) to attend and graduate from college? Yes No Publicity How did you hear about this program? (please check all that apply) College/Career Counselor Teacher Family/Family Friend Internet (please specify): Other (please specify): First & last name: Financial Information Parents’ Financial Data (to be completed if student is still in parents’ household or claimed as a dependent. Use data based on most recently filed tax form or Parents’ Information” on most “Your recent FAFSA form) Adjusted Gross Total Cash, Checking, Savings & Cash Value Income: of Stocks: (Form 1040 line 37) (exclude retirement plan funds, IRA, 401K) – Total Income of Father: Occupation of Father:
First name: Middle name/initial: Last name: Home phone: ) - Cell phone: ) - Date of birth: / Email address: Gender: Female Male Ethnic Heritage of… Mother: Maternal Grandmother: Maternal Grandfather: Father: Paternal Grandmother: Paternal Grandfather: Permanent Residence Address (Number & Street): Apartment/Suite: City: State: Zip Code: County (not Country): Mailing Address (if different from above) Address (Number & Street): Apartment/Suite: City: State: Zip/Postal Code: Parent or Guardian Information First name: Middle name/initial: Last name: Relation to applicant: Telephone: ) - Email address: Address (if different from above): Will you be the first in your immediate family (parents and siblings) to attend and graduate from college? Yes No Publicity How did you hear about this program? (please check all that apply) College/Career Counselor Teacher Family/Family Friend Internet (please specify): Other (please specify): First & last name: Financial Information Parents’ Financial Data (to be completed if student is still in parents’ household or claimed as a dependent. Use data based on most recently filed tax form or “Your Parents’ Information” on most recent FAFSA form) Adjusted Gross Income: (Form 1040 – line 37) Total Cash, Checking, Savings & Cash Value of Stocks: (exclude retirement plan funds, IRA, 401K) Total Income of Father: Occupation of Father:
2018-Lapiz-Family-Scholarship-Application.docx