APPLICATION FORM 2004-2005 ACADEMIC YEAR

Name: _________________________________________________________________________

Age: ____________________________________ Sex: __________________________________

Current Address: _________________________________________________________________

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U.S. Citizen Yes_____ No_____

Name and Address of Employer (if employed)

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High School Name: ___________________________________________________________

Address: ____________________________________________________________________

City/State/Zip: _______________________________________________________________

College/School Scholarship Intended for: ____________________________________________

Address/City/State/Zip: ___________________________________________________________

Major: _______________ Minor: ______________ Cumulative GPA: _______ SAT Score: _______

Student will live: ____ On-campus ____Off-campus ____Parents Home

Marital Status: ____ Single ____Married ____Divorced/Separated ____Number of children

List and describe any special academic accomplishments or awards you have earned._______________

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List all of your extracurricular activities. Describe the offices or positions you held and the extent of your

participation.____________________________________________________________________________

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Write one paragraph on: "Why I Should Be Awarded A Watts Scholarship Foundation Scholarship."

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Please develop a one to two page essay on a specific type of cancer. You can provide information on how cancer has impacted your life, or you may provide researched information. Also, think of a group or organization that you would like to share this information with. (We will distribute the awardees essay along with a cancer awareness information packet to the selected group or organization so that they may share the information with their members.)

STATEMENT OF CERTIFICATION AND RELEASE

All of the information provided herein is complete and accurate to the best of my knowledge. I hereby give the Watts Charity Association Committee permission to share this information among committee members for the purpose of evaluation. I further certify that I will enroll as a full-time, junior college or university student, that I am of African-American descent, and that I am a citizen of the United States of America. I authorize the Financial Aid Office to release pertinent information to the Watts Charity Association Committee. I am aware that falsification of information will result in the termination of any scholarship granted, and that all application materials will become the property of the Watts Charity Association Committee.

Signature: ________________________________________________________________________

Date: ______________ Email: _______________________ Fax: ___________________

REQUIRED INFORMATION: