JSRCC Scholarship Application

*First Name	*Last Name
*EMPL ID   (Your EMPL ID is required; every student is given an EMPL ID when admitted.)
*Street Address		*City
*Zip Code
County/City of Residence

*Home Phone		Work Phone
FAX		*E-mail
		Providing your email address will enable us to send you an email confirmation of receipt of your application.

*Date of Birth

*High School Graduation Date		Date of GED Certificate Received
*High School Attended			Dates of Attendance
College Attended			Dates of Attendance
College Attended			Dates of Attendance

 The Scholarship Committee in the selection process will consider each response to the following questions:  (If enough space is not provided below to answer these questions, please mail or fax additional sheets with your entire response to these questions.)  You are limited to 2000 characters in each of the sections below (including spaces and punctuation).

 Please read the following:

• If I am selected as a recipient, I hereby give my permission of J. Sargeant Reynolds Community College and the JSRCC educational Foundation to use my name, picture, narrative, and the fact that I was awarded a scholarship for promotional purposes.
   
• I hereby give permission to the JSRCC scholarship coordinator to obtain copies of all my transcripts on file in the JSRCC Admissions and Records Office.
   
• I also certify that the information contained in this application and any accompanying documents is true, complete, and correct to the best of my knowledge.

  Please click the box if you have read and agree to the following:
"I understand and accept the terms and conditions outlined in this application. I am aware that clicking this box also serves as an electronic proxy for my signature. I understand that failure to agree to the terms of the scholarship application may render my application incomplete."

 

After submitting your application, you will be shown a confirmation screen where you can review the information that will be submitted to the Scholarship Office.  Please use the back button on your browser to return to the form to make any corrections, then submit again.  Please print a copy of your confirmation for your files.