Scholarship Application Step 1 of 4 25% Check the school year for which you are applying: 2018-2019 2019-2020 Applicant InformationName First Last AgeSSN or ASU Mid-South ID#Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell Phone Applicant QuestionsPlease answer these questions completely. All incomplete applications will be discarded.Place of EmploymentNumber of Hours WorkedAre you a U.S. citizen or permanent resident alien?YesNoAre you an employee or dependent of an employee of Southland Gaming and Racing?YesNoAre you a parent?(child lives with you, and you/spouse provide more than 1/2 the total support)YesNoAre you a single parent?(child lives with you, and you provide more than 1/2 the total support)YesNoDateIf so please give the date. Date Format: MM slash DD slash YYYY Some 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.YesNo Organization NameAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact NameContact TitlePhoneHours per week Organization NameAddress Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact NameContact TitlePhoneHours per week Foundation Essay? Yes No Foundation Scholarship EssayIf you are interested in applying for foundation scholarships please complete an essay. Read essay requirements on page two.Name First Last Date Date Format: 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.
