JDO Scholarship Application

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Roxbury Multi Service Center, Inc.

John D. O’Bryant Education Center Scholarship

Application Form 2015

The following information must be on file before your application is considered complete: (Please use the following as a checklist to ensure that all documents are submitted)

q  Application Form (Handwritten, faxed or emailed applications will not be accepted)

q  Official high school transcript

q  Signed copy of Acceptance Letter from school you plan to attend

q  Two (2) Recommendation Letters, One (1) on official organization letterhead

q  Copy of 2015-2016 school cost (tuition, books, supplies)

q  Complete copy of Student Aid Report (SAR) – all pages

q  Copy of Financial Aid Award letter for the college or university you plan to attend

q  Disclosure of all pending scholarships

q  Short Personal Essay- max 1000 words (must be typed)

This application and all documentation must be submitted to RMSC-JDO Scholarship Committee by May 15, 2015

Mail to: John D. O’Bryant Education Center

c/o Roxbury Multi-Service Center, Inc.

434 Warren Street, Boston, MA 02121

Attention: Carole Montgomery

A. PERSONAL INFORMATION

Social Security Number

Name

First Middle Last

Home Address Street City State Zip Code

Mailing Address (if different)

Telephone Best time to call: Email Address: ______

Date of Birth Place of Birth

Country of Citizenship If not a U.S. citizen, are you a Permanent resident?

Race/Ethnicity Male Female

B. ACADEMIC INFORMATION

High School
Name
Address / Completion Dates / Program Name / Academic Standing or Rank
General Equivalency Diploma
Organization Name
Address
Home Study –Certifying Organization
Name
Address

Please list any academic awards or honors you have received:

If school of choice changes after the deadline, please forward acceptance letter as soon as possible. Please indicate the current status of your college application(s):

/

Admission Status – indicate school of choice with an (*) asterisk

Name of College/University / Accepted / Denied / Pending
1.
2.
3.
4.
5.
6.

C. Extra-Curricular Activities/Community/Volunteer Service

Dates
Organization / Beginning / Ending / Position Held / #Hours/Week
1.
2.
3.
4.
5.

D. Personal Essay

Please attach a short essay (maximum 1000 words) on the personal or career goals you have set for yourself. (Must be typed)

E. Scholarship Information

List all other scholarships, grants/loans for which you have or will apply for this year:

Application Status
/

Decision Status

Scholarships/Grants/Loans / Applied / Will Apply / Approved / Denied
1.
2.
3.
4.
5.
6.

If any award (scholarship/grant/loan) has been refused, please explain the reason(s) for refusal. Prior to any awards of monies a final update must be submitted to scholarship committee.

Please attach two (2) reference letters. The two letters should be a combination of a community leader, teacher, clergy, supervisor, and/or adult mentor. This person should know of your academic abilities, be familiar with your character and your ability to set and meet goals and overcome challenges.

By signing below, I affirm that all information contained on this application is true and accurate to the best of my knowledge. I also fully recognize that any misrepresentations found on this form may result in me being declared ineligible for a scholarship award. An application is INCOMPLETE without your signature.

Signature Date

*DID YOU SUBMIT ALL PERTINENT DOCUMENTS? - PLEASE UTILIZE THE CHECKLIST AT THE BEGINNING*