State Scholarship Request Form
Please complete this form to request disbursement of your Miss Louisiana Scholarships. A copy of the Scholarship Rules & Regulations can be found at www.misslouisiana.org.
Contestant Name
*
First Name
Last Name
Miss or Teen
*
Miss
Teen
I am a Full-Time Student
*
Yes
No
I receive Louisiana TOPS Scholarship
*
Yes
No
I receive Other Scholarship Assistance
*
Yes
No
I certify that as of the date of this request, I am currently enrolled as a full-time student, in an accredited undergraduate program, or a graduate program, leading to an academic degree, and that I am submitting this form to request scholarship funds. If you have outstanding scholarships owed by a local preliminary, those funds must be exhausted before requesting your state scholarships. I further agree I will abide by all IRS rules for scholarship payments to tuition-only degree programs, and acknowledge that any attempt to receive funds fraudulently, or apply funds in a taxable manner, may result in my forfeiture of any remaining scholarship and possible criminal charges.
*
Phone Number
*
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Social Security #
*
Date of Birth
*
-
Month
-
Day
Year
Name of Academic Institution/College or University
*
Degree Program Enrolled
*
Student ID
*
Mailing Address of College or University
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email for College Cashier's Office/Student Financial Affairs
*
example@example.com
Scholarship was awarded at
*
Miss Louisiana 2025
Miss Louisiana's Teen
Do you have unpaid scholarships through a local preliminary competition?
*
Yes
No
Amount of scholarships owed from locals.
*
Name of Local Scholarships Awarded
*
Type of Scholarship Awarded
*
Letter or Email From Local Director Confirming that all Scholarships have been exhausted on the local level.
*
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Name of Parent/Guardian (if contestant is a minor)
First Name
Last Name
Email of Parent/Guardian (if contestant is a minor)
example@example.com
Phone Number of Parent/Guardian (if contestant is a minor)
Please enter a valid phone number.
Format: (000) 000-0000.
Scholarship Request Summary. Name type of award, the year and the total amount of the award you are requesting. Scholarships are awarded for TUITION ONLY and you must be currently enrolled in school with full-time credit load. If you are requesting only a portion of the funds, or have requested funds previously please include in the summary.
*
Tuition & Course Statement/Schedule (outlining classes for the upcoming semester)
*
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NO Screenshots or Estimated Bills may be Used. Invoice must show all TOPS and other Scholarship Payments.
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Additional Notes
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