STEPHEN P. GORMAN SCHOLARSHIP RENEWAL APPLICANT
Missouri University of Science and Technology SEMESTER: Spring 2012
Personal Information:
NAME:______Student Number ______
Last First MI
PERMANENT ADDRESS:______
Street
______
City State Zip
LOCAL ADDRESS:______
Email address:______
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High School you graduated from:______
Address, City and State:______
Currently Enrolled Students:
Major Field of Study at Missouri S&T:______
Expected Graduation Date:______
Level: ____(0-29 hrs)FR ____(30-59 hrs)SOPH ____(60-89 hrs)JR ____(90 +hrs)SR
______Graduate level Cumulative Grade Point Average:______
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TO BE COMPLETED BY MISSOURI S&T STUDENT FINANCIAL ASSISTANCE OFFICE:
This is to verify that the above applicant has been reviewed by Missouri S&T Student Financial Assistance Office for consideration of financial need.
Established Need:______
Grants: ______
Scholarships: ______
Date:______
Signature and Title of Financial Asst. Officer
**Applicant MUST complete reverse of form**
AFFIDAVIT TO ESTABLISH ELIGIBILITY
I, ______, upon my oath, state as follows:
1. I am a full-time student currently registered and in good standing, or have been accepted for admission, pursuing an ENGINEERING degree at Missouri University of Science and Technology.
2. My home or permanent residency is in St. Louis, Missouri.
3. I have graduated or will graduate from a high school in the City of St. Louis.
4. I understand that each Gorman Scholarship award is subject to review and possibly withdrawn at any time without any cause or reason necessary at the sole discretion of the Gorman Foundation Trustees.
5. I am aware that each Gorman Scholarship is NOT automatically or in any way guaranteed to be renewable and that I MUST reapply and establish my eligibility for each semester.
6. I give my permission to Missouri S&T to provide a copy of my Missouri S&T academic transcript to the Gorman Foundation.
Date: ______Applicant’s Signature: ______
Subscribed and sworn to before me this ______day of ______20 ____.
Notary Public Signature: ______
My Commission Expires: ______
This application MUST be returned to:
STUDENT FINANCIAL ASSISTANCE OFFICE
Missouri University of Science and Technology
300 W. 13th Street
G-1 Parker Hall
Rolla, MO 65409-0250
APPLICATION DEADLINE: November 18th