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| | First Name*
| Last Name*
| Preferred Name
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| Permanent Address
Street Address*
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| City*
| State*
| Zip*
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| School Address
Street Address*
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| City*
| State*
| Zip*
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| Preferred Phone*
| Preferred Email Address*
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| School*
If other, please enter your current school here:
| Year in School*
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| Current Overall GPA
| High School or College GPA
High school
College | Graduation Month / Year
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| How did you hear about the eXceed Scholars program?
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If you are not a US Citizen, US Permanent Resident, Temporary Resident, Refugee or Asylee, do you have legal right to work in the US?
Yes
No
If Yes, please explain:
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IN SUBMITTING THIS VERIFICATION, I HEREBY CERTIFY THAT I AM *:
Black/African American
Census 2000 - refers to people having origins in any of the Black racial groups of Africa
Hispanic/Latino
Census 2000 - refers to a person of Cuban, Mexican, Puerto Rican, Central or South American or other Spanish culture or origin regardless of race
American Indian/Native American and Alaska Native
Census 2000 - refers to people having origins in any of the original peoples of North and South America (including Central America), and who maintain tribal affiliation or community attachment. |
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