Student Application Form

Christina M. Liston Scholarship

Instructions: Please Print Clearly or Type and return completed form to:

Christina M. Liston Scholarship Committee
c/o Margaret Connell, English Department
CCRI Liston Campus
One Hilton Street
Providence, RI 02905

Applications must be hand delivered by 4 p.m. or postmarked no later than April 1.

Name________________________________________ Student I.D. #_____________________

Address_________________________________ City________________ State____ Zip_______

Telephone__________________________________ email_______________________________

1. Are you a graduating student? Yes__ No__

2. Have you achieved a minimum grade point average of 3.5? Yes__ No__

3. Have you attended the Liston Campus? Yes__ No__

4. Have you been accepted at a four-year institution for continued studies toward a bachelor’s degree in
business, computer science, or a related field? Yes__ No__

5. List the extracurricular activities in which you participated while you attended CCRI and describe your role and responsibilities in each. (Attach additional pages as necessary.)

6. Provide examples of your personal initiative and/or leadership qualities when you were at CCRI. (Attach additional pages as necessary.)

7. Have you applied for other CCRI scholarships, funds or awards? Yes___ No___

If yes, please list:

I grant my permission to the Scholarship Review Committee to review my academic standing with CCRI’s Office of Admissions and Records, to review my financial need with CCRI’s Financial Aid Office, and to use my name and photo for publicity purposes. I understand that all scholarship committee decisions are final.

___________________________________________
Student Signature/Date

____________________________________
Student Signature/Date

Important Note: Scholarship recipient is required to write a thank you note (memo and sample thank you note) to the scholarship donor, and provide a brief biography (printable bio form) about themselves and their education/career goals and return both to: Geraldine Peixoto, CCRI Foundation, Flanagan Campus, 1762 Louisquisset Pike, Lincoln, RI 02865. Please contact the CCRI Foundation if you need assistance in completing this responsibility at 333-7150 or e-mail at foundation@ccri.edu.