Return completed applications to:

NE Indiana IU Alumni Association; 6106 Belle Isle Lane; Fort Wayne, IN 46835
Due June 15, 2014


Check one
Mr.
Ms.


Phone
Number Cell Phone Number Date of Birth

E-mail Address


IU Issued I.D. OR
Last four (4) Digits of
Social Security #

COLLEGE/UNIVERSITY INFORMATION
Do you plan to attend IU-Bloomington in the fall? Yes No
City /State:
Major Field of Study:
Degree to
Obtain:

ACADEMIC INFORMATION

**Attach a copy of your most current transcript to this application**

GPA

Type of High School Diploma: Core 40 Diploma Academic Honors Diploma


I am a member of the 21
st
Century Scholar Program. Yes No
.

Next year I will be a:

freshman sophomore junior senior graduate student








First Middle Last
Address
City State Zip
2014-2015 Scholarship Application
Northeast Indiana Chapter




WORK HISTORY AND SCHOOL/COMMUNITY ACTIVITIES

Work History Include summer and school year employment. Start with your most recent job.
Employer Nature of Work Start/Finish Date
Hours per
Week
Hourly
Pay




School Activities Include all school-related activities such as band, athletics, student government, etc.

Activity
Year



Hours
per
Week
Leadership position/awards
FR SO JU SR
FR SO JU SR
FR SO JU SR
FR SO JU SR
FR SO JU SR
FR SO JU SR
FR SO JU SR
FR SO JU SR
FR SO JU SR
FR SO JU SR

Community Activities volunteer, religious, scouts, etc.

Activity
Start/Finish
Date
Hours per Week Leadership position/awards












STUDENT ESSAY

Using the space below, Pick an experience from your own life and explain how it has influenced your
development. Use only the space provided on this sheet.































Student Signature: ________________________________________ Date: ______________