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Roxbury Multi Service Center, Inc. John D. O’Bryant Education Center Scholarship Application Form 2015

The following information must be on file before your application is considered complete: (Please use the following as a checklist to ensure that all documents are submitted) q Application Form (Handwritten, faxed or emailed applications will not be accepted) q Official high school transcript q Signed copy of Acceptance Letter from school you plan to attend q Two (2) Recommendation Letters, One (1) on official organization letterhead q Copy of 2015-2016 school cost (tuition, books, supplies) q Complete copy of Student Aid Report (SAR) – all pages q Copy of Financial Aid Award letter for the college or university you plan to attend q Disclosure of all pending scholarships q Short Personal Essay- max 1000 words (must be typed) This application and all documentation must be submitted to RMSC-JDO Scholarship Committee by May 15, 2015 Mail to: John D. O’Bryant Education Center c/o Roxbury Multi-Service Center, Inc. 434 Warren Street, Boston, MA 02121 Attention: Carole Montgomery A. PERSONAL INFORMATION

Social Security Number

Name First Middle Last

Home Address Street City State Zip Code

Mailing Address (if different)

Telephone Best time to call: Email Address: ______

Date of Birth Place of Birth

Country of Citizenship If not a U.S. citizen, are you a Permanent resident?

Race/Ethnicity Male Female

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B. ACADEMIC INFORMATION

High School Completion Dates Program Name Academic Standing Name or Rank

Address

General Equivalency Diploma Organization Name

Address

Home Study –Certifying Organization Name

Address

Please list any academic awards or honors you have received:

If school of choice changes after the deadline, please forward acceptance letter as soon as possible. Please indicate the current status of your college application(s):

Admission Status – indicate school of choice with an (*) asterisk Name of College/University Accepted Denied Pending 1. 2. 3. 4.

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C. EXTRA-CURRICULAR ACTIVITIES/COMMUNITY/VOLUNTEER SERVICE

Dates Organization Beginning Ending Position Held #Hours/Week 1. 2. 3. 4. 5.

D. PERSONAL ESSAY

Please attach a short essay (maximum 1000 words) on the personal or career goals you have set for yourself. (Must be typed)

E. SCHOLARSHIP INFORMATION

List all other scholarships, grants/loans for which you have or will apply for this year: Application Status Decision Status Scholarships/Grants/Loans Applied Will Apply Approved Denied 1. 2. 3. 4. 5. 6.

If any award (scholarship/grant/loan) has been refused, please explain the reason(s) for refusal. Prior to any awards of monies a final update must be submitted to scholarship committee.

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Please attach two (2) reference letters. The two letters should be a combination of a community leader, teacher, clergy, supervisor, and/or adult mentor. This person should know of your academic abilities, be familiar with your character and your ability to set and meet goals and overcome challenges.

By signing below, I affirm that all information contained on this application is true and accurate to the best of my knowledge. I also fully recognize that any misrepresentations found on this form may result in me being declared ineligible for a scholarship award. An application is INCOMPLETE without your signature.

Signature Date

*DID YOU SUBMIT ALL PERTINENT DOCUMENTS? - PLEASE UTILIZE THE CHECKLIST AT THE BEGINNING*