Fillable P.O. Box 667 Black River Falls, WI 54615 (Ho-Chunk Nation)

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P.O. Box 667 Black River Falls, WI 54615 (Ho-Chunk Nation)

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Country of origin: US
File type: PDF

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2019 SUMMER
HO-CHUNK SCHOLARSHIP
Complete in ink. Incomplete and/or illegible applications will be returned to the student.
439A00-
TRIBAL ID NUMBER
LAST NAME
FIRST NAME
MI PREVIOUS
/
MAIDEN NAME
-
-
/ /
□ MALE □ FEMALE □ OTHER
□ PHONE □ E-MAIL □ MAIL
SOCIAL SECURITY NUMBER
DATE OF BIRTH
(
MM
/
DD
/
YY
)
GENDER
PREFERRED COMMUNICATION
MAILING ADDRESS (WHILE ATTENDING SCHOOL) CITY
STATE
ZIP
PERMANENT ADDRESS (IF DIFFERENT FROM MAILING ADDRESS)
CITY
STATE
ZIP
PRIMARY PHONE NUMBER
ALTERNATE PHONE NUMBER PRINT EMAIL
/
FAFSA FILING DATE
(
MM
/
YY
)
COLLEGE
/
UNIVERSITY YOU WILL ATTEND
COLLEGE
/
UNIVERSITY LOCATION
:
CITY
,
STATE
CURRENT YEAR IN SCHOOL/CREDITS EARNED FOR INTENDED DEGREE:
□
FRESHMAN 1-30
□
SOPHOMORE 31-60
□
JUNIOR 61-90
□
SENIOR 91-120
□
GRADUATE # CR. ___
□
NO CREDITS/UNSURE
DEGREE SEEKING:
□ TECHNICAL DIPLOMA/CERTIFICATE □ ASSOCIATE □ BACHELOR’S □ MASTER’S □ JURIS DOCTORATE □ DOCTORATE
MILITARY BENEFITS: U.S. VETERAN :
□ YES □ NO
MILITARY BENEFITS
:
□ STATE □ FEDERAL □ PARENT/SPOUSE
PRESENT EMPLOYMENT STATUS:
EMPLOYED: □ YES □ NO WORK STATUS WHILE ATTENDING SCHOOL: □ FULL-TIME □ PART-
TIME
HO-CHUNK NATION EMPLOYEE: □ NO □ YES DEPARTMENT:
ADDITIONAL INFORMATION NEEDED FOR SUMMER SCHOLARSHIP CONSIDERATION:
VALID CLASS SCHEDULE (MUST SHOW STUDENT NAME, SCHOOL NAME, COURSE TITLE, CREDITS AND TERM)
ITEMIZED SUMMER BILLING STATEMENT FROM THE SCHOOL (ELECTRONIC OR PAPER COPY)
COPY OF THE FINANCIAL AID AWARD LETTER FROM THE SCHOOL (ELECTRONIC OR PAPER COPY)
PROVIDE AN OFFICIAL GRADE TRANSCRIPT (TO CLOSE OUT PREVIOUS FUNDING) TO DETERMINE ELIGIBILITY
PROVIDE AN ACCEPTANCE/ADMISSION LETTER
COPY OF CDIB (CERTIFICATE DEGREE OF INDIAN BLOOD), IF NOT PREVIOUSLY PROVIDED
STUDENT CONSENT & RELEASE OF INFORMATION
The information given by me on this form is accurate and complete to the best of my knowledge. By signing this application I am granting
permission for my post-secondary institution or my prospective institution to share my information, including STUDENT FAFSA RECORD
INFORMATION to the Ho-Chunk Nation Higher Education Division. I give permission for my financial aid and academic information to be shared
among the following funding agencies: Bureau of Indian Affairs, Ho-Chunk Nation, State, and the Financial Aid Office at my school. I understand
I may be required to complete a separate release of information for any additional inquires.
SIGNATURE OF APPLICANT STUDENT’S LEGAL NAME (PRINTED) DATE
H
IGHER
E
DUCATION
D
IVISION
P.O. Box 667
Black River Falls, WI 54615
(800) 362-4476
Fax: (715) 284-1760
higher.education@ho-chunk.com
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P.O. Box 667 Black River Falls, WI 54615 (Ho-Chunk Nation)

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Completed 23 December 2020

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