Scholarship Application Online Form

Use this form to apply for the annual Dr. Diters scholarship.

First Name: *

Last Name: *

Street Address: *

City: *

State: *

Zip Code: *

Student Email Address: *

Please enter a valid email address for the student

Father's Name:

Father's Occupation:

Mother's Name:

Mother's Occupation:

Home Phone: *

Schools/Colleges Accepted: *

List all schools/colleges to which you have been accepted

School Attending: *

Field of Study: *

SAT Score Critical Reading: *

Enter your highest SAT Critical Reading score

SAT Score Math: *

Enter your highest SAT Math score

SAT Score Writing: *

Enter your highest SAT Writing score

Estimated Expenses: * $

Statement of Financial Need for One Year: Tuition, room & board, fees, books, supplies, various personal expenses, transportation)

Family Contribution: * $

Statement of Financial Need for One Year: What is the expected Family Contribution amount?

Your Contribution: * $

Statement of Financial Need for One Year: What is the expected amount of your contribution?

FAFSA Filed: *

Did you file a F.A.F.S.A? (Yes or No)

Other Family Members: *

What is the number of family members in post-secondary education next year? (At least 1/2 time)

Other Financial Aid: *

What other scholarships or financial aid from any source have you already been offered? Please state source and amount (Pell Grant, Awards, Scholarships, Loans, Grants).

FAILURE TO DISCLOSE ANY OF THE ABOVE MAY RESULT IN LOSS OF AWARD

Other Circumstances:

Please report any unusual family or personal circumstances you feel warrant attention

Statement of Objectives and Goals: *

Write a statement of your plans as they relate to your educational and career objectives and future goals.

Activities: *

Please list all activities that you participated in.

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Scholarship Application Online Form

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