Quinetta Brundge Legacy of Giving Scholarship Application Form I, have read and understand the conditions of the Quinetta Brundge Legacy of Giving Scholarship explained in the information packet. I affirm that I plan to pursue a career in one of the disciplines as listed in those documents. I give permission to officials of my previous or current institution to release transcripts of my academic record and other information requested for consideration for the Quinetta Brundge Legacy of Giving Scholarship. I understand that this application will be available only to qualified individuals who need to see it in the course of their duties. I waive the right to access letters of recommendation written on my behalf. I affirm the information contained herein is true and accurate to the best of my knowledge and belief. Date Signature Legal name in full (Print/Type) Last Name First Name M.I. Permanent residence Number, Street, and Apartment Number Your address at school (if different) City State ZIP Number, Street, and Apartment Number How is permanent residence established? (At least two must apply.) Home address for school registration Place of registration to vote Family s primary residence City (if studying abroad, add country) State ZIP Home telephone ( ) School telephone (if different) E-mail address ( ) Other: Date of birth Age Month/Day/Year (Check one) I am a U.S. citizen U.S. national Resident alien expecting citizenship by the date of award single mother Current cumulative GPA Your major(s) Number of college credits earned to date Expected date to receive degree dependent of a head of the household member who is a single woman on a scale of Total number of credits required for graduation Degree you will receive I have attached with my application: Previous years federal income tax returns, and/or tax returns of the head of my household 2 letters of recommendations or character reference letters. Official High School and/or College Transcripts Official school documents showing your declared major (if you are a 1 st year entering student)
1. List the secondary school from which you graduated and all higher education institutions attended. School Location Dates Attended 2. List college and high school activities (student government, sports, publications, school-sponsored community service programs, student-faculty committees, arts, music, etc.). List in descending order of significance. You will have space for eight college and four high school activities. College Activity Dates Offices High School Activity Dates Offices 3. List public service and community activities. Do not repeat items listed previously. List in descending order of significance. You will have space to list six. # of Weeks Activity Role Dates Active Application 2 of 5
4. List all part-time and full-time jobs you have worked in the last 5 years. Type of Work Employer Dates Average # of Hours/Week 5. Describe one specific example of your ability to persevere through hardship, adversities, and pursue a goal. Application page 3 of 5
Approved for use through 08/03 6. Describe a recent particularly satisfying public service activity (do not repeat experience described in 3). 9. Describe the problem or needs of society you want to address when you enter your chosen field of discipline. (If possible, use statistical data to define the magnitude of the problem.) 10. What are the three most significant courses you have taken in preparation for your career? 11. If selected as a Quinetta Brundge Legacy of Giving Scholar, would you be willing to donate 10 hours of service back to the community in your first year of using the scholarship by volunteering with one of our community projects? Application page 4 of 5
12. What do you hope to do specifically in the nursing industry and what type of nursing position do you hope to have five to seven years later 13. What additional personal information do you wish to share with the Quinetta Brundge Legacy of Giving Scholarship Committee? Application page 5 of 5