Applicant Information
Full name:  
Current address:   Permanent address:
Phone number:     Mobile:  
Email address:     Date of Birth (mm/dd/yyyy):  
College/University presently attending:  
City, State:   Degree seeking & Major:  
Date started:
  Expected graduation date:    
Cumulative GPA:
(on a 4.0 scale)
  Major GPA:
(on a 4.0 scale)
  Name and location (city, state) Degree/Date Major
High School:
Honors/Scholarships awarded:
Additional Questions
Are you able to present evidence of your U.S. citizenship or proof of your Permanent Resident status?
Yes No
What race/ethnicity do you consider yourself to be? (Check all that apply)
 Black or African American
 Hispanic or Latino
 Native North American
What is your gender?  
Male Female
Have you ever been convicted of a criminal offense? (Excluding minor traffic offenses)
Yes No
If yes, please state the nature of the crime(s), when and where convicted and the disposition of the case.
Have you ever been the subject of any disciplinary action taken by a college or university?
Yes No
If yes, please explain the circumstances.
 I certify that I have not knowingly withheld any information that might adversely affect my chances of being offered the Scholarship and that the answers given by me are true and correct to the best of my knowledge. I further certify that I have personally completed this application. I understand that any omission or misstatement of material fact on this application or any other document used to obtain the Scholarship shall be grounds for rejection of this application.

   I authorize Franklin Park to thoroughly investigate my references, work records, education, driving record, credit history, criminal background and other matters related to my suitability for being offered the Scholarship. I further authorize the employers, schools, and other references I have listed to disclose to Franklin Park any and all documents, transcripts, letters, reports, and other information related to these references, without giving me prior notice of such disclosure. I further authorize an investigative consumer report from an agency such as Equifax. I hereby release Franklin Park, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosures.


Please describe your career goals and how this scholarship will help you achieve these goals. Please limit your response to 250 words.


OTHER Attachments
Reference letter (optional):