Scholarship Application "*" indicates required fields Step 1 of 4 25% Check the school year for which you are applying:* 2022-2023 2023-2024 Applicant InformationName First Last Date of Birth* MM slash DD slash YYYY ASU Mid-South ID#If available Address* Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Home PhoneCell PhoneAre you a U.S. citizen or permanent resident alien?YesNo Applicant QuestionsPlease answer these questions completely. All incomplete applications will be discarded.Have you Graduated from High School?*Select OneYesNoIf NO are you a senior? Name of High School Are You Employed?*Select OneYesNoNumber of Hours Worked Are you an employee or dependent of an employee of Southland Gaming and Racing?*Select OneYesNoWho is employed by Southland Gaming? Are you a parent?*(child lives with you, and you/spouse provide more than 1/2 the total support)Select OneYesNoAre you a single parent?(child lives with you, and you provide more than 1/2 the total support)YesNoSome scholarships offer preference to students with disabilities. Would you like to be considered for these?By selecting “Yes,” you understand written verification from a physician or social services provider may be required.Select OneYesNo Do you have any community service activities that you would like to report?*Select OneYesNoOrganization Name Location Contact Name Contact Title Phone Hours per week Foundation Essay?*Select OneYesNoPlease Upload Your Essay File!Max. file size: 128 MB.Without an essay, your scholarship application will only be looked at for Academic Scholarships.Name* First Last Date* MM slash DD slash YYYY Certify Your Application* I agree I certify that the information on this application is correct. Should I be awarded this scholarship, I agree to give strict attention to my studies and to the regulations of ASU Mid-South. ASU Mid-South is authorized to make this information available to scholarship donors and scholarship committees. I grant ASU Mid-South permission to release information from my acaemic records to document my eligibility for the award. I also agree to the use of my name, picture, and essay, if required, for news releases should I receive the scholarship. I agree to be present at the annual Foundation Scholarship Luncheon should I be awarded a Foundation scholarship. I understand any award offer is conditional to my meeting eligibility requirements and the continued availability of donor funds which may be revoked with or without notice at the donor’s discretion.Signature*Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
