Good Neighbor Scholarship Application

Good Neighbor Scholarship Application
Personal Information
* Required
Name*

First NameMiddle NameLast Name
Permanent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residence*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Date of Birth*

MonthDayYear
Date
Please check the box that most appropriately indicates your status*

U.S. CitizenPermanent Resident of U.S. (Not a U.S. Citizen)International Student
Resident Alien ID #
Country
Passport Number
Please indicate your ethnic origin. (This information is optional and requested for use on federal and state reports as well as institutional research. Ethnic origin is not used to determine one's eligibility for admission.)
How would you describe your racial background? Please select one or more of the following categories:

WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsianNative Hawaiian or Other Pacific Islander
Are you Hispanic or Latino?

YesNo
Gender

MaleFemale
Religious Affiliation

CatholicOther
Do you have health insurance? If so, please list company name and policy number. If you do not have insurance, you have the option of purchasing a plan through Divine Word College.
Name of Insurance Company
Policy Number
Academic Information

List the name of each high school in order of attendance. If high school equivalency is based on the GED Test, please give the date you completed the GED and the total passing score you received. Please send an official transcript from your school(s) or GED completion certificate and test scores to the Admissions Office. Contact your school and request that they send a copy to Divine Word College.
Name of first high school attended*
Required
City/State of first high school*
Required
Dates of Attendance:
From:
Month*
Year*
To:
Month*
Year*
Average grades in school - (grade point average/GPA)*
Required
Name of second high school (if attended more than one)
City, State of second high school:
Dates of Attendance
From
Month
Year
To
Month
Year
Graduation date from high school/secondary school
Month*
Year*
If you did not graduate from high school/secondary school, did you pass a high school equivalency exam like the General Educational Development (GED) exam?

YesNo
For applicants who attended high schools in the United States, if you took the SAT or ACT tests, please indicate:
Date of Scholastic Aptitude Test (SAT):
Month/Year
Verbal Score for SAT Test:
Math Score for SAT Test:
Date of American College Test (ACT):
Month/Year
Composite Score for ACT Test:
For applicants whose first language is not English, please answer the following questions:
What is your first language?
Have you ever taken the TOEFL Test (or an alternative English Language Test)?

YesNo
Name of Test
Date of Test

MonthDayYear
Date
Test Score
Have you studied English in a formal classroom setting?

YesNo
If yes, how long did you study English? (How many years, semesters, etc.)
How many hours per day did you study?
What is your estimated level of English language proficiency?

BeginnerIntermediateHigh IntermediateAdvanced
College/University Education (if any): List the name and location of any colleges or universities you attended in order of attendance. We require that you list all institutions and request an official transcript from each institution be sent to the Admissions Office. If you intend to apply for transfer credit for courses already taken please send a syllabus or a course description for each course for which you request transfer credit.
Name of college/university attended
Required
City/State of first college/university
Required
Dates of Attendance:
From:
Month
Year
To:
Month
Year
College GPA
Credit Hour Load
Number of credits earned or degree
Have you ever been on Academic Probation?

YesNo
Have you ever been on Disciplinary Probation?

YesNo
If you answered yes to either question above, please explain:

Emergency Information

In case of emergency, please list the name, address, phone number and relationship of someone the college can contact.
Name *

First NameLast Name
Relationship to you*
Phone Number*

Area CodePhone Number
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What is your intended area of study at Divine Word College?

Associates Degree - Theology and MissionAssociates Degree - Intercultural StudiesAssociates Degree - Interdisciplinary Studies
Personal Statement: Please share why you wish to study at Divine Word College and what you hope to do after earning your A.A. degree. Write as much as you would like.

PLEASE READ THIS STATEMENT BEFORE SUBMITING APPLICATION!

I CERTIFY THAT ALL STATEMENTS OR INFORMATION I HAVE PROVIDED ABOVE ARE TRUE AND THAT, IF ADMITTED, I AGREE TO BE GOVERENED BY THE REGULATIONS, POLICIES AND ACADEMIC STANDARDS OF DIVINE WORD COLLEGE. WHEN SUBMITTING THIS APPLICATION, I AUTHORIZE THE USE OF APPLICATION MATERIALS BY THE ADMISSIONS COMMITTEE FOR CONSIDERATION OF MY APPLICATION. SUBMITTING THIS APPLICATION DOES NOT GUARANTEE ADMITTANCE TO DIVINE WORD COLLEGE.
Name of Applicant*

First NameLast Name
Date Signed by Applicant*

MonthDayYear
Date
Should be Empty:

Good Neighbor Scholarship Application

Academic Information

Emergency Information