Application must be received by March 15, 2010.
|
|
General Instructions |
Personal Data
|
|
Extracurricular Activities, Affiliations and Honors
|
Work Experience
|
|
Citizenship
|
Academic Background
|
|
Personal Statement
|
|
| General Instructions: |
• All application materials must be typed.
• Thoroughly review your application for accuracy and completeness.
• Essays must have one-inch margins on all sides, be double-spaced, typed in Times New Roman 11-12 pt. font, and include the applicant’s name and essay title in the header on each page. Essays should be a minimum of 500 words.
|
| Checklist for Complete Application: |
|
Mail official transcript, two letters of reference, recent photo and SAR in one envelope to
CBCF Louis Stokes Health Scholarship Program
Congressional Black Caucus Foundation
1720 Massachusetts Avenue, NW
Washington, DC 20036 |
|
| Personal Data |
| Last Name |
Invalid Input |
First Name |
Invalid Input |
| Gender |
Invalid Input |
Date of Birth |
Invalid Input |
| Address |
Invalid Input |
City |
Invalid Input |
| State |
Invalid Input |
Zip + 4 |
Invalid Input |
| Permanent Telephone Number |
Invalid Input |
Emergency Telephone Number |
Invalid Input |
| Email Address |
Invalid Input |
| Father’s Name |
Invalid Input |
Occupation |
Invalid Input |
| Mother’s Name |
Invalid Input |
Occupation |
Invalid Input |
| U.S. Representative who |
Invalid Input |
|
| Extracurricular Activities, Affiliations and Honors (e.g., Sports, Clubs, Greek Organizations, Community Organizations) |
| High School: |
Invalid Input |
| College: |
Invalid Input |
|
| Work Experience (including internships) |
| Company / Organization Name |
Invalid Input |
| Dates Employed |
Invalid Input |
Title/ Job Description |
Invalid Input |
| Location |
Invalid Input |
| Company / Organization Name |
Invalid Input |
| Dates Employed |
Invalid Input |
Title/ Job Description |
Invalid Input |
| Location |
Invalid Input |
|
| Citizenship: |
| Are you a U.S. Citizen? |
Invalid Input |
| If you are not a U.S. Citizen by birth, please indicate: |
| Birth Citizenship |
Invalid Input |
| Date of Naturalization |
Invalid Input |
Place of Naturalization |
Invalid Input |
| Are you legally eligible to work or study in the U.S.? |
Invalid Input |
| Visa Type |
Invalid Input |
Date of Expiration |
Invalid Input |
|
| Academic Background: |
| Previous Institution/high school |
Invalid Input |
| Degree |
Invalid Input |
Date Degree Received or Expected |
Invalid Input |
| Major(s) |
Invalid Input |
Minor(s) |
Invalid Input |
| GPA |
Invalid Input |
|
| Current Institution |
Invalid Input |
| Degree |
Invalid Input |
Date Degree Received or Expected |
Invalid Input |
| Major(s) |
Invalid Input |
Minor(s) |
Invalid Input |
| Current Classification |
Invalid Input |
GPA |
Invalid Input |
| Undergraduate Institution |
Invalid Input |
| Degree |
Invalid Input |
Date Degree Received |
Invalid Input |
|
| Personal Statement |
On a separate sheet of paper, type a document that responds to all of the following topics in one essay. The
personal statement should be a minimum of 500 words.
- Future goals: What field of study (major) do you plan to pursue? Why have you chosen that field? How
will this field of study help you to achieve your future career goals?
- Involvement in school activities, community and public service, hobbies and sports: Do you have any special
talents or other areas of interest?
- Deserving of scholarship: How will receiving this award affect your current and future plans?
- Other experiences, skills or qualifications: What else do you feel should be considered in reviewing your
application?
|
| Upload statement |
|
|
* This field is required.
