GEAR UP

GEAR UP / Hathaway Scholarship Application

First Name:

Last Name:

Address:

City:

State:

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Zip Code:

Phone:

Social Security Number:

Email Address:

I am applying for the WWCC GEAR Up Scholarship beginning in the following term and year:

Fall

Spring

I plan to enroll:

Which type of student are you: Select High School Graduate GED Graduate Home Schooled Student

Month and Year of High School graduation, GED completion or Home school graduation:

Month Select 1 2 3 4 5 6 7 8 9 10 11 12

Year Select 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980

High School Name:

All applicants who apply for this scholarship must also complete the FAFSA (Free Application for Federal Student Aid) and apply for need based aid. Have you completed the FAFSA? Select Yes No

If you have not yet completed the FAFSA, what date do you plan to complete it by?

Month: Select 1 2 3 4 5 6 7 8 9 10 11 12 Day: Select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 2012 2013

Are you a US citizen?

If a male over 18 years old, have you registered with selective service?

Are you in default on a federal Title IV education loan?

Do you owe a refund on a federal Title IV student aid program?

Have you been convicted of a felony in this state or another jurisdiction?

I verify under penalty of false swearing under Wyoming Statute 6-5-303 that the above information is correct.