Student’s Name: ________________________________________ Date of Birth: _______________Grade: ___
Student’s Address: ___________________________________ City ___________________ Zip ____________
Student’s Phone Including Area Code: ______________________ Student’s Email: _______________________
Name of High School: ____________________________ Name of School District: _______________________
Name of Contact Person (Counselor, Teacher, or Other): ____________________________________________
The Contact Person must be someone who knows you well, who is aware of your Personal Narrative, and is
someone who has your permission to verify the content of your essay.
School Contact’s Phone Including Area Code: __________________ Contact’s Email: _____________________
My future career plans are to attend (check as appropriate)
_______ College ________________________________________________________________
_______ Vocational School ________________________________________________________________
_______ Military ________________________________________________________________
_______ Employment ________________________________________________________________
Type of Employment
I hereby authorize my school to release a transcript and other information, as may be necessary concerning this
scholarship application.
I hereby authorize the person designated above as Contact Person to verify the content of my Personal Narrative
and/or to clarify questions, if necessary.
I hereby verify that I am a senior in good standing and will graduate at the end of the current academic year.
_________________________ ___________ __________________________ __________
Student’s Signature Date Parent/Guardian’s Signature Date
Enclosed, in addition to this application form, please find all of the following items intended to
complete my application for the Anthony Brucia Award:
1. A Personal Narrative, which tells your story. It describes the obstacles you have faced, your progress
despite difficulties and your plans for future success
2. Two letters of recommendation
3. Activities record and employment history
4. Transcript freshman through first semester of your senior year
5. Make sure phone number and email address are in good working order.
Applications must be postmarked no later than Friday, April 9, 2021 and mailed to Sergio
Mendoza at the address shown on the cover letter accompanying this application.
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