Instructions:  Complete this form, sign and date it, and return the form along with ALL the scholarship applications to:  Geraldine Peixoto, CCRI Foundation, Flanagan Campus.  Upon receipt of all the applications and the sign-off form, the Office of Institutional Advancement will process the scholarship award within two weeks and mail the check to the selected recipient.

Name_________________________________ Student I.D. #___________________________

Address_____________________________ City___________________ State____ Zip______

Telephone_______________________________ email________________________________

1.  Is the applicant an incoming student and/or a continuing student?  Yes__ No__

2.  Is the student in one of the following programs of study?  Yes__ No__

Allied Health Yes__ No

Business Administration  Yes__ No__

Computer Studies Yes__ No__

Engineering & Technology  Yes__ No__

General Programs Yes__ No__

Nursing  Yes__ No__

Administration office Technology  Yes__ No__

3.  Have you verified the students G.P.A.?  Yes__ No__

4.  Did the selected recipient submit an essay on why they should receive this scholarship?  Did he/she include information on their leadership skills?

5.  Does the selected recipient meet all scholarship eligibility requirements?  Yes__ No__

How many applications were received?  __________

Who was on the selection committee?

_______________________________

_______________________________

_______________________________

_____________________________________________________
Scholarship chair signature/date

Student Recipient must agree to continue/become a member of SkillsUSA at CCRI.