DSU
DEPENDENT STUDENT
SCHOLARSHIP APPLICATION
Name of Applicant: _______________________________DSU ID #____________________________
(do not use social security #)
Relationship to Employee__________________________ Contact Telephone Number______________
Employee_______________________________________ Number of Years at MDCC______________
Semester and Year Applying For: ____________________Number of Hours Applying For:__________
This application needs to be submitted 6 weeks before semester and year applying for
Student Date
Employee Date
Appropriate Supervisor Date
Associate Vice President / Vice President Date
President Date
After all signatures have been obtained, the President’s office will forward this form to Human Resources. HR will forward the
form to DSU.
Mississippi Delta Community College does not discriminate on the basis of age, race, color, national origin, religion, sex, sexual
orientation, gender identity or expression, physical or mental disability, pregnancy, or veteran status in its educational programs
and activities or in its employment practices. The following person has been designated to handle inquiries regarding the nondiscrimination policies: Steven J.
Jones, Vice President of Administrative Services, Tanner Hall, Suite 202, P. O. Box 668,
Moorhead, MS 38761, 662-246-6304; EEOC@msdelta.edu
Updated 11/17/2020