______________________

      Social Security #                                                                 Continuing                Transferring

 

______________________          _______________________        ______________________

      Last Name                                First Name                                      Middle Name

 

____________________________________   __________________     _____   ____________

      Street Address                                                  City                              State                  Zip

 

______________________          ______________________________  __________________

      Area Code & Phone                   College                                                 Major

 

_____________________________________________________________________________

      Address of College

 

SECTION 2 – SPECIAL DATA

 

This section is optional.  If you choose, check all that apply.  If you do not complete this section, you may be ineligible for some scholarships.

 

1.   Sex

                  Female             Male

 

2.   Special Groups

                  Disabled            EOPS               Re-Entry Student

                  Single Student with dependent child(ren)

                  Veteran             Child of Veteran

                  Currently on active duty

3.   Honors

                  Alpha Gamma Sigma                 Phi Alpha Mu                       Psi Beta

                  Mu Alpha Theta                         Honors Program

 

FOR OFFICE USE ONLY

                  GPA                 Units Completed            Current Units           Entered

4.   There are specific scholarships offered in these categories.  Mark all boxes that describe you.  Be sure to justify these answers in the remainder of your scholarship application or in the required personal essay.  Mark each item that applies with an “X”.

 

            I plan to be a teacher.

            I am an international student.

            I plan to be a nurse or pursue a health-related field.

            I do volunteer work in the community or at the college.

            I work (paid or volunteer) to assist the disabled.

            I am employed at least 30 hours per week.

            I am a student leader or am active in campus activities.

            I frequently use the OCC Library.

            I am a member of the crew team.

            I work (paid or volunteer) in substance abuse prevention or wellness.

            I am actively involved to improve the environment.

            I have children who are enrolled at the Harry & Grace Steele Children’s Center

 

SECTION 3 – ACADEMIC INFORMATION

 

1.   High School Name __________________________________________________________

 

2.   Location _______________________________________   Year of Graduation _________

 

3.   List all colleges you have attended in the United States since August 1997, most recent first.

 

            College                                          Location                                        Dates

 

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

 

You are responsible to have each college send transcripts to you to include with application.

 

 

 

 

4.   Objective at OCC (check all that apply)

            AA Degree                          Transfer (to which college?) _________________________

            Certificate                            Other (describe) __________________________________

5.   Describe your specific educational career plans for the next five to ten years.  Attach an additional sheet if necessary.

 

6.   If you have withdrawn from three or more classes or if you have any incomplete grades on your transcripts, please explain.  Otherwise, write “Not Applicable”.  Attach an additional sheet if necessary.

 

 

 

1.   College/High School Activities:  Student government, athletic teams, forensics, performing groups, honorary memberships, clubs, teaching assistantships, etc.  List activities since August 2000, most recent first.  Attach additional sheet if necessary.

 

a. Group _____________________________________      Which year(s)  __________________

Hours per week __________ Advisor’s Name _______________ Phone      _________________

School ___________________ If this was a part of a class, which one?    __________________

List your responsibilities         ______________________________________________________

 

b. Group _____________________________________      Which year(s)  __________________

Hours per week __________ Advisor’s Name _______________ Phone      _________________

School ___________________ If this was a part of a class, which one?    __________________

List your responsibilities         ______________________________________________________

Did you receive pay for this?       Yes                  No

2.   Community Volunteer Work: Civic organizations, church work, youth work, etc.  List only items for which you did not receive pay.  List activities since August 2000, most recent first.  Attach an additional sheet if necessary.

 

a. Group _____________________________________      Which year(s)  __________________

Hours per week __________ Advisor’s Name _______________ Phone      _________________

School ___________________ If this was a part of a class, which one?    __________________

List your responsibilities         ______________________________________________________

 

b. Group _____________________________________      Which year(s)  __________________

Hours per week __________ Advisor’s Name _______________ Phone      _________________

School ___________________ If this was a part of a class, which one?    __________________

List your responsibilities         ______________________________________________________

3.   List other experiences that demonstrate your leadership

 

4.   If you have no record of service and leadership at high school, college, or in the community, it would be to your advantage to explain why.  Attach an additional sheet if necessary.

 

5.   Employment:  List all PAID jobs since August 2000, most recent first.  Attach an additional sheet if necessary, but DO NOT attach your resume.

 

a.   CURRENT JOB

Company Name __________________________________      Supervisor   _________________

Location         ___________________________________________________________________

Start Date ___________________ End Date _________________ Hours/week       ___________

List typical duties        ____________________________________________________________

 

a.   PREVIOUS JOB

Company Name __________________________________      Supervisor   _________________

Location         ___________________________________________________________________

Start Date ___________________ End Date _________________ Hours/week       ___________

 

b.   PREVIOUS JOB

Company Name __________________________________      Supervisor   _________________

Location         ___________________________________________________________________

Start Date ___________________ End Date _________________ Hours/week       ___________

List typical duties        ____________________________________________________________

6.   If you have no record of employment, it would be to your advantage to explain why.  Attach an additional sheet if necessary.

 

 

1.   List all people who are financially dependent on you.

 

            Name                      Relationship to you        Age                                                                  percent (%) of support you provide

 

2.   Spouses

      Name _________________________________     Occupation    __________________________

      Employer         __________________________________________________________________

      Employer Address        ___________________________________________________________

      Is your spouse a student?     Yes                  No              Where? __________________________

3.   Parents                         Mother                                            Father

     

      Number of dependents supported by your parents       Percent of your support provided by

      Do not include your parents                    _______            parents or others                 _______

 

4.   Living accommodations

      Check all who contribute to your room and board

            Self             Parent            Spouse          Children         Other Relative    Other person

      Check all who live with you

            Alone          Parents          Spouse          Children   How Many? _______

            Other Relative                   Roommate

 

 

Please proceed to page 7 of the application.

 

 

 

 

 

SECTION 6 – FINANCIAL DATA FOR THE YEAR 2003

 

 

1H  Gov’t Assistance       _____________________________________________________________

 

1J   Legal Awards, Scholarships

      Student Grants or Loans        ______________________________________________________

 

1K  Other Income       ________________________________________________________________

 

 

2L   Other Expenses        _____________________________________________________________

 

3.   If your total income (Line 1G) is less than your total expenses (Line 2G), explain how you are managing to meet your needs.  Failure to provide this explanation could jeopardize your chance for a scholarship award.  Attach an additional sheet if necessary.

 

4.   Please list any major financial obligations that are not described previously.

 

      Total obligation $ _____________