First Name    Last Name    Date 

Physical Address 

Mailing Address 

Phone: HOME      WORK 

Last 4 Digits of your  SSN#

Are you currently residing in Randolph County?  Yes   No

How long have you lived in Randolph County? 

If you are currently employed, where do you work and what is your position?

Are you the Head of Household? (Single living on your own or single with dependents).

Yes  No  If you answered "Yes", how many additional dependents in you household? 

Do not include yourself in this total- if no dependents type a 0 in the space provided.

Academic Information

1. School Involvement

Name of School you are currently attending 

Year Graduated or year you expect to graduate 

2. Undergraduate Degree

Highest Earned Degree 

Major 

Granted By  (Name of college or university)

Date Received

3. Plans for next Academic Year

Name of College/University you will be attending 

Will you be attending  Part time (less than 12 hours)    Full time

Have you be4en formally accepted into your chosen program of study?  Yes  No

Anticipated Date of Graduation 2005 2019 2020 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Financial Information