Scholarship Recipient Data Form

Name(Required)

First Last

School Name(Required)

Social Security Number(Required)

School Student Identification Number(Required)

Current Photo(Required)

Max. file size: 50 MB.

Financial Aid Office

Because we are under IRS Code 501(c)(3) and it dictates that our scholarship may only be used for tuition, books and fees ALL schools must sign an agreement that they will adhere to this stipulation in dispensing your scholarship. Contact your school and ask to whom we should email the scholarship agreement AND where to send the check after the signed agreement is returned to us. Students attending the following schools do not need to complete this section. I have this information for these schools: Carnegie Mellon University, Case Western Reserve University, Grove City College, Kettering University, The Ohio State University, Penn State University, University of Pittsburgh, Purdue University, University of Virginia, Westminster College, and West Virginia University. IF YOU DO NOT ATTEND ONE OF THE ABOVE LISTED SCHOOLS, ALL OF THE SECTIONS BELOW ARE REQUIRED!

Name of School Contact

Phone Number of School Contact

Email of School Contact

Check should be mailed to

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date(Required)