APPLICANT INFORMATION

Name *

First

Last

Date of Birth *

Place of Birth *

Email *

Current address *

Address Line 1

Address Line 2

City

State

Zip Code

Program of Study *

Phone *

Anticipated start date *

EMPLOYMENT INFORMATION

Current Employer *

Employer address

Address Line 1

Address Line 2

City

State

Zip Code

Industry *

Phone *

How long did you work? *

Position *

Salary *

EMERGENCY CONTACT

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Relationship *

REFERENCES

1

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship

2

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship

3

Name

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship

EDUCATION BACKGROUND

High School Information

High School Name *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Graduation Date *

College/University Information

College/University Name *

Degree *

Graduation Date *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

GPA *

SPECIAL ACHIEVEMENT/HONORS AND RECOGNITIONS

NAME

CURRENT MEMBERSHIP OR LICENSES

NAME

ELIGIBILITY REQUIREMENTS

Requirements

– Student Official Transcripts
– Driver’s license or passport
– Proof of residency
– W-2 forms (US citizens and residents)
– Other yearly records of money earned (If applicable)
– Other Documents you judge will be of favor.

Conditions:

Student must maintain a cumulative GPA of 3.0 and be continuously enrolled; withdrawing from school or not starting classes in the first semester will result in ineligibility

INCOME-BASED SCHOLARSHIP

Layout

A & B

A

B

Household Income Eligibility

Annual gross income less than $ 30,000.00 in the year prior to the application.

Annual income greater than $ 30,001.00 and less than $ 40,000.00 in the year prior to the application.

Scholarship (%)

50%

35%

WHICH ONE DOES IT APPLY TO YOU FROM ABOVE? *

A
B

SIGNATURE

I authorize the Academy of Mid Florida to verify the information provided on this form including References, Education and Employment background. By writing my name below this application, I understand that I am applying for a scholarship that pertains to my area of study and that I am responsible for maintaining my grades in good standing. I also understand that I must always represent the Institution in a positive manner and that failure to follow these expectations can and will lead to the revocation of my academic scholarship. I understand that if I drop, withdraw, or fail any of the courses at the Academy of Mid Florida I will be held
responsible for tuition costs and all additional student fees associated with continuing my education at the school.

Name *

First

Last

Today's Date *