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__

Industrial Technology 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?

_______________________________

_______________________________

_______________________________

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Scholarship chair signature/date

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