2008 FCB SCHOLARSHIP APPLICATION
It is recommended that this application be copied and pasted into a document editor then completed and printed afterwards.
Please indicate which award you are applying for:
( ___ ) $2,000.00 Academic Excellence
( ___ ) $1,500.00 Career Enhancement
( ___ ) $750.00 Part-time Student
I. PERSONAL DATA:
Name: _________________________________________________
Address: ________________________________________________
City/State/Zip: ____________________________________________
SS #: ___________________________________________________
Summer Address (if different from above):
______________________________________________________________
City/State/Zip: ____________________________________________
Phone (Day): ( ____ )_____________________________________
Phone (Evening): ( ____ )_____________________________________
Male _______ Female _______
Date of Birth: ___________________
II. VISUAL STATUS:
Check all the methods you use for reading:
( __ ) Braille ( __ ) Recordings ( __ ) Large Print ( __ ) Regular Print
( __ ) Live Reader
III. EDUCATIONAL BACKGROUND:
A) Name and address of school in which you are currently enrolled or last attended:
Name: __________________________________________________
Address: ________________________________________________
City/State/Zip: ____________________________________________
Cumulative grade point average (based on 4.0 scale): ____________
Major: ___________________________ Number of hours: ____________
Degree/Certificate sought: _____________________________________
Date degree expected: _____________________________________
B) School you plan to attend in the fall (if different from above)
Name: __________________________________________________
Address: ________________________________________________
City/State/Zip: ____________________________________________
Major: __________________________ Number of hours: _____________
Degree/Certificate sought: __________________________________
Date degree expected: _____________________________________
C) List any secondary or post-secondary schools which you have attended:
Name of School: __________________________________________
Address: ________________________________________________
City/State/Zip: ____________________________________________
Cumulative grade point average (based on 4.0 scale): ____________
Dates Attended: From: _________________ To: _________________
Name of School: __________________________________________
City/State/Zip: ____________________________________________
Cumulative grade point average (based on 4.0 scale): ____________
Dates Attended: From: _________________ To: _________________
IV. WORK EXPERIENCE
Please attach a list of any full-time or part-time work experience you may have. Indicate whether this is summer employment or during
the school year.
V. EXTRACURRICULAR ACTIVITIES
Please attach a list of any major outside activities (school, church, community, e.g., sports, organizations, recreation, etc.). Indicate extent
to which you have played a leadership role.
Applications MUST include a SEALED official transcript and be postmarked no later than March 31st, 2008. Please mail this application,
along with any attached paperwork EXCEPT for the CERTIFICATION OF VISUAL STATUS to the following address:
Florida Council of the Blind
c/o Barbara Grill
2030 Preymore Street
Osprey, FL 34229
(941) 966-7056
grillbh@comcast.net
VI. CERTIFICATION OF VISUAL STATUS
To be completed by an ophthalmologist, optometrist, physician, agency executive serving the blind or other competent authority.
THE ENTITY COMPLETING AND SIGNING MUST MAIL THIS FORM DIRECTLY TO THE FLORIDA COUNCIL OF THE BLIND
This is to certify that the person named on this scholarship application is known to me and is legally blind. The entity certifying the
applicant’s vision status MUST complete and mail this form in a separate envelope to the address below.
Cause of Visual Impairment: ____________________________
Visual Acuity: Right eye: ____________ Left eye: ____________
Name: _____________________________________________
Title: ______________________________________________
Address: ___________________________________________
City/State/Zip: _______________________________________
Telephone number: __________________________________
Signature: _________________________ Date: ____________
Mail the CERTIFICATION OF VISUAL STATUS to:
Florida Council of the Blind, Inc.
c/o Barbara Grill
2030 Preymore St.
Osprey, FL 34229
(941) 966-7056
If you have any questions, contact Barbara at (941) 966-7056 or via E-mail at
grillbh@comcast.net.
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