Workforce Development Scholarship
Revised 02/19/2020
Scholarship Application
All questions must be answered for the application to be considered.
Print legibly or type.
Name ___________________________________________ SSN# xxx – xxx - ___ ___ ___ ___
Mailing Address ____________________________________________________________________
County of Residence ____________________ Home/Cell Phone ( ) _________________________
Email address __________________________ Do you live with your parents? □ Yes □ No
Age _________ Student’s Marital Status □ Single □ Married □ Separated/Divorced
Are other family members in college? □ Yes □ No If yes, who and where? ____________________
List your dependents and their ages_____________________________________________________
Program of study _______________________________ Program Coordinator ____________________
Class start date ____________ Completion date __________ Course Code ____________________
Previous education: □ HS Diploma □ GED/Adult High School Diploma □ College graduate
Name of high school ___________________________ Are you a veteran? □ Yes □ No
Are you working now? □ Yes □ No If yes, how many hours per week? ______________________
Employer’s name ________________________________ Position ____________________________
1. Student/spouse’s 2019 Income (include wages, unemployment benefits etc.) ___________________
2. Student/spouse’s 2019 Non-Taxable Income (child support, Social Security, etc.) _______________
If you are 23 or under, not married, and have no dependent children, please provide:
3. Parents’ 2019 Income (include wages, unemployment benefits, etc.) __________________________
4. Parents 2019 Non-Taxable Income (child support, Social Security, etc.) _______________________
5. Total 2019 Income for your household (Total lines 1, 2, 3, and 4) _________________________
EDUCATIONAL AND EMPLOYMENT INFORMATION
INCOME INFORMATION- Complete in full so that we can have an idea of your family’s financial situation.
Please provide a copy of your taxes, if available.
