Please refer to the Scholarship Guidelines before completing this form. Last Name First Name Middle Initial Date of Birth DCC Student ID Number Mailing Address Mailing Address City State - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming ZIP Code City/County of Residence Phone Number Student Information Program of Study at DCC (please be specific) Are you enrolled in a science, technology, engineering, math, or health curriculum? If yes, please complete the STEM-H Financial Assistance Application found on the DCC Educational Foundation Scholarship webpage. Yes No What is the Student Aid Index (SAI) listed on your FAFSA? Are you entitled to veterans’ benefits? Yes No If you answered yes to the previous question, what type of veterans’ benefits do you receive? Are you eligible for veterans’ rehabilitation benefits? Yes No Are you receiving any type of assistance for tuition or books? Yes No If you answered yes to the previous question, what assistance are you receiving for tuition or books? During the fall semester, how many credits do you plan to take at DCC? Part-time (up to 12 credits) Full-time (12 or more credits) Prior Academic Information High School Attended Graduation Month - Select -JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Graduation Year High School Grade Point Average Your Rank in your Graduating Class If high school graduation information is unavailable, please explain why. If you are not a high school graduate, what date did you receive your GED? Do you have a bachelor’s degree? Yes No Additional Information Please name two people, preferably your former teachers and not related to you, as references. Include a contact telephone number. Are you aware of any DCC scholarship(s) for which you are specifically qualified? If so, please name the scholarship(s) and provide reasons why you should be considered. Did you receive any DCC Educational Foundation Scholarships in the previous academic year? Yes No If you answered yes to the previous question, which scholarship(s) did you receive? Extracurricular Activities (clubs, sports, hobbies, talents, special interests): Community Activities (e.g. volunteer work): Accomplishments (honors received, scholarships awarded): Please include an informational essay (minimum 300 words required) about yourself, your goals, and your reasons for applying for this scholarship. Applications that fail to meet the 300-word essay requirement may be disqualified. Leave this field blank
