Last Name: ____________________ First Name: ____________________________ Middle Initial: ______
Mailing Address: ______
______________________________________ City: ________________________
State: ___________________ ZIP: _______________ Telephone Number: (____)_____-_______________
Palo Verde College Student ID #: ______________ First Time College Student: Yes
High School Students – List the year you graduated from High School or when you will graduate: _________
College Students – If you are a returning student who has not attended college in two
years or more, please
list the year you last attended: _________
I hereby give my authorization, permission and consent to the scholarship organizations for which I have
indicated on the cover page of this application to use, disclose, release, and/or publish my name, photo, and
any other information which I have provided or which in the future I may provide in promotional materials,
including, but not limited to, news releases, brochures, and advertising.
I also give my authorization, permission and consent to the scholarship organizations for which I have
indicated on the cover page of this application to contact and receive information from any institution,
agency, college/university, and/or persons for the following purpose: a) to verify the information I have
provided; and b) to obtain any other information concerning my scholastic status in order to assess my
qualifications and/or eligibility for this scholarship.
The authorization, permission and consent I have hereby given shall remain in force and effect unless I
revoke this consent in writing by letter addressed to the Financial Aid Department, Palo Verde College.
I hereby verify that all the information I have provided is complete and accurate to the best of my knowledge.
I further acknowledge and agree that any incomplete or false information will result in my application not
Applicant Signature Date
Please Answer: Would you have applied to PVC if not for this CHOICE scholarship offering free tuition?
Instructions: This is a fillable form. You may fill it out and then print and sign it, or simply print it first and then
complete the application and sign it.
Section I. CONTACT INFORMATION
Section II. EDUCATIONAL INFORMATION
Section III. STUDENT CONSENT AND SIGNATURE