Northwest State Community College • 22600 State Route 34 • Archbold • OH • 43502
Phone: 419-267-1333 • Fax 419-267-5587
Student Name: ____ __________________________________ NSCC ID number: N_______________________
Address: ___________________________________________ Home Phone Number: (_____)________________
City: _________________ State: _____ Zip Code: ____________ Cell Phone Number: (_____)______________
County: ____________________________ Email Address: ____________________________________________
Birthdate: __________________________
Projected NSCC Graduation Date: ______________________ I am attending: Full time Part-Time
I or a family member is employed at one of the following companies? Check all that apply
Arrow Tru-Line CK Technologies Automatic Feed Allied Moulded Spangler Candy
Name & relationship of family member:_______________________________ ** Your name and family members name will be shared with a company
representative to verify employment
I have an immediate family member that is a graduate of NSCC? Yes No
Name of Graduate: _______________________________ Relationship (ex. Father): _____________________________
Last 4 digits of their SSN: ____________ Graduates date of birth ____________________
I or my spouse/parent(s) are a Veteran(s)? Yes No If yes, list relationship ________________________
I have filled out the 2020-2021 FAFSA? Yes No I am a member of PTK? Yes No
Describe how a scholarship will impact your educational goals?
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Describe your involvement/volunteering in your community or on campus.
______________________________________________________________________________________________
______________________________________________________________________________________________
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Share any information you would like the scholarship committee to know about you (i.e. financial, personal, educational, etc.).
______________________________________________________________________________________________
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Information obtained through this application and from your student record will be shared with the scholarship committee in order to successfully determine scholarship
eligibility. By signing this form, I Certify that all the information reported is complete and correct. If selected as a scholarship recipient, I give permission for my name to be
shared in marketing materials and press releases.
Student Signature: __________________________________ Date:______________________
Northwest State Community College does not discriminate on the basis of race, color, national origin, sex, gender identity, disability, religion or age in its programs or activities.
2020-2021
Scholarship Application
Henry County residents provide copy of unexpired state ID Office Use: Verify__________
Office Use: NSCC Verify_____________
Application is due in the NSCC Financial Aid Office by 4:00 pm on February 14, 2020
