Arizona Council of the Blind, INC. 3124 E. Roosevelt St., Ste. 4 Phoenix, AZ 85008-5088 (602) 273-1510
2010 Scholarship Packet Checklist:
* REQUIRED FIELD: Name: Address: City: State: Zip Code:
Telephone Number: * REQUIRED FIELD. Day: Evening: Cell:
* REQUIRED FIELD. E-mail Address:
Permanent and/or legal address and telephone number (if different from above): Address: City: State: Zip Code: Phone number:
Male/Female: Female Male >
TODAY'S DATE (MM/DD/YYYY):
Date of Birth:
Class level for upcoming fall term: Cumulative Grade Point Average: Major field of study:
Do you read Braille? Yes I Read Braille No I Don't Read Braille>
Will you be a full-time student? (Note: full-time is considered 12 or more credit hours per semester for undergraduates, and 9 or more credit hours for graduate students.) Yes I I will be full time> No I will not be full time>
Please note: Legal blindness is defined as an individual who has a visual acuity of 20/200 or less in the corrected eye and/or 20 degrees or less visual field in the corrected eye. Legal blindness must exist in BOTH eyes to be considered eligible. When did you begin having problems with your vision? At what age did you become legally blind? Cause of visual impairment: Visual Acuity: Right Eye: Left Eye: Visual Field: Right Eye: Can you see well enough to tell whether the light is on or off? Yes I can see light> No I can't see light> Sometimes see steps going down? Yes I can see steairs going down> No I an't see stairs going down> Describe the types of mobility aids you use for travel: cane, guide dog, other devices. Describe the media you choose for reading, the types of hardware or software you use including devices and technology you use including screen reader, notetaker, magnification devices, etc.
A. (Entering Freshmen only)? High school currently attending: Name: City: State: Cumulative GPA (based on 4.0 scale):
B. College or technical college currently attending: Name: City: State: full-time? (Yes/No) Yes I am full time> No I am not full time> Cumulative GPA (based on 4.0 scale): Date degree is expected: Major(s) and Degree seeking (BS, MA, etc): C. School you plan to attend in the fall (if different from question III. B.). Note: Proof of acceptance must be included with application materials. If you will not be notified of acceptance by the time you submit this application, please indicate the date you expect to receive notice from the school(s): ?1st Choice: Name: City: State: Major and Degree: full-time? (Yes/No) Yes Full Time No> Not Full Time Date degree expected: 2nd choice: Name: City: State: Major and Degree: full-time? (Yes/No) Yes Full Time No> Not Full Time Date degree expected: D. Please list all schools you have attended during the last four years if not mentioned above. Attach additional sheet, if necessary. Name: City: State: Dates (mo/yr) attended: ?From: To: Cumulative grade point average (based on 4.0 scale): Major and Degree or certificate received (if applicable): IV. TEST RECORD INFORMATION ACT Date tested: Composite Score: SAT Date tested: Composite Score: SAT II Subject: Date tested: Composite Score: Other (GRE, GMAT, LSAT, etc.) specify: Date tested: Composite Score: V. WORK EXPERIENCE In the space provided, list any full-time or part-time work experience in the last ten years. Indicate whether this was summer employment or during the school year. ?Work experience: VI. EXTRACURRICULAR ACTIVITIES A. Are you a member of the Arizona Council of the Blind or the American Council of the Blind? B. Have you received an AzCB or ACB scholarship in the past? If so list the year(s). ?Your application will be shared with the national organization, ACB. C. May we refer this application to another source of possible scholarship aid? D. In the space below, list your extracurricular activities (school, religious, community, sports, organizations of the blind, recreation, etc.). Include the extent to which you have played a leadership role. A co-curricular transcript may be substituted. ?Extracurricular activities: Autobiographical sketch: Tell us about your personal goals, strengths, weaknesses, hobbies, honors, achievements, etc. Be sure to list the field or courses of study you are pursuing and explain why you have chosen it. How did you hear about the AzCB or ACB scholarship program? Please note: In some instances, scholarship awards may be considered taxable income by the Internal Revenue Service. Comments" Submit will send an E-mail of your request to the Scholarship Committee of the AzCB. Return to AzCB Web Site
C. School you plan to attend in the fall (if different from question III. B.). Note: Proof of acceptance must be included with application materials. If you will not be notified of acceptance by the time you submit this application, please indicate the date you expect to receive notice from the school(s): ?1st Choice: Name: City: State: Major and Degree: full-time? (Yes/No) Yes Full Time No> Not Full Time Date degree expected:
2nd choice: Name: City: State: Major and Degree: full-time? (Yes/No) Yes Full Time No> Not Full Time Date degree expected:
D. Please list all schools you have attended during the last four years if not mentioned above. Attach additional sheet, if necessary. Name: City: State: Dates (mo/yr) attended: ?From: To: Cumulative grade point average (based on 4.0 scale): Major and Degree or certificate received (if applicable):
How did you hear about the AzCB or ACB scholarship program?
Please note: In some instances, scholarship awards may be considered taxable income by the Internal Revenue Service.
Comments"
Submit will send an E-mail of your request to the Scholarship Committee of the AzCB.
Return to AzCB Web Site