2016 Scholarship application

2016 Scholarship application
(Please review the requirements before completing this form)

STUDENT INFORMATION - PART I

* Indicates required field

Name *

First

Last

Date of Birth *

Gender *

Male Female

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell phone *

Home phone *

Student'sEmail *

Father / Guardian *

Mother / Guardian *

Age *

Address if different from student's *

Phone if different from student's *

SCHOOL INFORMATION

HIGH SCHOOL NAME *

City of High School *

PRINCIPAL *

Phone Number *

COUNSELOR *

Phone Number *

LETTERS OF RECOMMENDATION

NAME *

Title *

NAME *

Title *

We, the undersigned, hereby certify that the information contained in this application is true to the best of our knowledge, and grant the Vietnamese Physician Association of Northern California (VPANC) full authority to verify said information. If the applicant becomes a recipient of the Scholarship Award, the VPANC is thereby authorized to publish and disseminate said information at its discretion, and shall be held harmless from all claims, liabilities, or legal actions that may arise therefrom.

STUDENT SIGNATURE *

PARENT / GUARDIAN SIGNATURE *

Date *

EXTRACURRICULAR ACTIVITIES - PART II

List all your extracurricular activities, achievements, awards, ect. Limit to 1 page. *

ESSAY - PART III

Write an essay on any topic you choose. You may use English or Vietnamese. Limit to 1 page *

Upload Transcripts *

Max file size: 1 MB

Upload 2015 income tax return *

Max file size: 1 MB

Upload first letter of recommmedation *

Max file size: 1MB

Upload second letter of recommmedation *

Max file size: 1 MB

Upload student portrait photo *

Max file size: 500 kb

Submit