1 | P a g e
CANNON SCHOLAR PROGRAM
Please provide the following information. All information is confidential. If you are concerned about any of the questions asked on this form, please discuss them
with the Cannon Scholar Program PI (Principal Investigator), Dr. Malcolm J. D’Souza, firstname.lastname@example.org, or the Associate Director of Student Success
and Retention, Ms. Danielle Archambault, email@example.com. To be considered for a scholarship award, all outlined application requirements
must be fully complete and submitted via e-mail to Ms. Archambault by the specified deadline for the semester that you are applying. If all requirements are
not fully complete by the semester deadline, then your application will be denied.
I am applying for a scholarship - due by May 1
Name (Last, First Middle Initial)
Yes No M F
Major (mark all that apply)
Year in School (this fall)
Anticipated Graduation Date
Freshman Sophomore Junior Senior
Ethnicity (mark all that apply)
Asian American Alaska Native Black/African American Pacific Islander Other
Caucasian Latino/Hispanic American Native Hawaiian Native American/American Indian
1. I certify all of the above information to be true and I hereby authorize the PI or the Director of Student Success to disclose or obtain educational records and
information with any faculty or staff member, as deemed appropriate by the Cannon Scholar Program staff.
2. I hereby authorize the Financial Aid Office at Wesley College to release my financial aid information to the Director of Student Success.
Applicant’s Signature Date
Wesley College will not discriminate on the basis of race, color, creed, religion, national origin, sex, sexual orientation, age, marital status, or status with regard to
public assistance in its admission, employment, programs or activities.
FOR OFFICE USE ONLY
Federal Financial Aid Received
___Subsidized Stafford Loan
___Unsubsidized Stafford Loan
___ Other Federal Scholarships Name:
___Financial Need totals more than $4,250 OR ________________
Unofficial Transcripts Verified?
<< All 3 of the following application materials
are due by May 1