1 SAMPLE APPLICATION Pages in the Application 1. Eligibility 2. Student Information 3. Race and Ethnicity 4. Academic Information 5. Academic Plans 6. Activities 7. Work Experience 8. Financial Information 9. Essay 10. Instructions to Mail your Transcript 11. How Did You Hear About WSOS? 12. Agreement/Consent 13. Submit Eligibility You must answer each question below. You are eligible to apply for the Washington State Opportunity Scholarship if you answer YES to each of the statements below. If you have any questions, please or call You have received or will receive your high school diploma from a Washington State high school, a tribal high school located in Washington State, or a GED from Washington State by June, Please note: If you graduated from a high school outside of the state of Washington you are not eligible to apply. 2. You are a Washington state resident, ( as defined in RCW 28B ). 3. You are currently a high school senior, or a college freshman or sophomore. Please note: College students who will have earned 90 or more quarter credits or 60 or more semester credits at the start of fall term 2015 are not eligible. Running Start, AP, IB and transfer credits that your college has accepted count toward that total.
2 4. You will be pursuing one of the eligible high-demand majors in science, technology, engineering, math (STEM) or health care included on the following list: (eligible majors by alphabet; eligible majors by category). Please note: If your major is not on the list linked above, you are not eligible to apply. 5. You will be pursuing your first bachelor s degree, (i.e. four-year degree), at one of the listed eligible Washington State colleges/universities. Please note: If you will be attending a public community or technical college Fall 2015 that does not offer a four-year degree in your eligible high-demand major you must be planning to transfer to one of the four-year colleges/universities referenced above by the time you have earned 90 quarter credits. 6. Your cumulative grade point average (GPA) through fall quarter/semester 2014 must be a minimum of 2.75 (on a 4.0 scale). Please note: If your college/university or high school does not provide a GPA, or you received your GED, please answer "yes" and your academic progress or score will be verified during the application review process. 7. You will enroll full-time (at least 12 credits per quarter/semester) each term during the academic year. 8. You are eligible to file and will submit the Free Application for Federal Student Aid (FAFSA) at by March 9, You meet the total family income requirement (adjusted gross income plus all untaxed income) for 2014 based on this chart. Please note: If you qualify to submit the FAFSA as an independent student, the family income amounts are those reported by you (including spouse and children, if applicable) rather than your parents. Dependent students must use their parents income. I meet all the eligibility criteria listed above.
3 Student Information First Name Jenny Middle Name Elizabeth Last Name Smith Date of Birth 2/11/1992 Gender Female Social Security Number ***-**-1111 Please note: If this number does not match the SSN on your filed FAFSA, your application will not be considered. Mailing address 1123 Main St City Tacoma State Washington ZIP Code Preferred Phone Number Type of Phone Number Cell Phone Secondary Phone Number Type of Phone Number Preferred Re-enter Preferred Please note: will be the primary means of communication. Therefore, please use a valid address that you check regularly. If it changes notify us promptly. Please make sure is an approved sender you may need to check your spam settings. You will be notified of your selection status via the you provide above. Race and Ethnicity Your answers to the following questions will allow the program administrator to report requested information to the Washington State Opportunity Scholarship Board, the Washington State Legislature and other interested parties such as the Washington Student Achievement Council and private donors. These questions are not required and the answer will not be used for selection of this scholarship. NOTE: The following questions adhere to the U.S. Department of Education Standards for gathering information about a student's race and ethnicity and use the following guidelines: American Indian or Alaska Native (a person having origins in any of the original peoples of North and South America, including Central America, and who maintains tribal affiliation or community attachment) Asian (a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam) Black or African American (a person having origins in any of the black racial groups of Africa) Native Hawaiian or Other Pacific Islander (a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands) White (a person having origins in any of the original peoples of Europe, the Middle East, or North Africa)
4 Are you of Hispanic/Latino descent (a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture/origin, regardless of race)? No Additionally, what race(s) do you consider yourself? Regardless of your answer to the previous question, please mark the following box(es) to indicate what you consider yourself to be. White Academic Information High School Diploma I have or will receive my high school diploma from a Washington State High School, Tribal School or Running Start Washington State High School or Tribal School from which you received or will receive your diploma (Running Start students, please enter your high school, not college). Wilson High School State Washington Month of high school diploma or GED receipt 6-June Year of high school diploma or GED receipt 2015 Current Enrollment I am currently Graduated High School - Enrolled in College At which college have you earned the most credits? Tacoma Community College Where are you currently enrolled? Tacoma Community College Where were you enrolled fall term 2014? Tacoma Community College Is that college/university on a quarter or semester system? Quarter Through the end of fall 2014, how many college credits will you have earned? Earned college credits include Running Start and AP or IB credits. Please include all earned credits from current and previous colleges attended. Enter total number of earned credits listed on your official college transcript: 90 Expected completion date of first bachelor s degree Month 6 - June Year 2018 Parent(s)' Education Level What is the highest level of education completed by either of your birth or adopted parents? Some college, no degree
5 Your Grade Point Average Your cumulative grade point average (GPA) through fall quarter/semester 2014 must be a minimum of 2.75 (on a 4.0 scale). If you have not yet graduated from high school, enter your high school cumulative GPA through fall quarter/semester If you are a Running Start student, please report the GPA from your official high school transcript. Check with your high school to ensure that your Running Start classes for fall quarter are included in your GPA. Please note: If your high school does not use GPA, please select "My high school does not use GPA". If you are currently enrolled in college/university, report your college/university cumulative GPA through fall quarter/semester Please note: If your most current GPA is from The Evergreen State College please select "The Evergreen State College" from the drop down menu below and your academic progress will be verified with the college. If you have graduated from high school, but have not yet enrolled in college, enter your high school cumulative GPA. If you graduated from high school, attended college/university, but were not enrolled fall quarter/semester 2014, enter your cumulative GPA from the college/university from which you earned the most credit. If you received your GED, enter the score. Please provide GPA through two decimal eligibility points e.g My GPA is from College Transcript My GPA is 3.47 Academic Plans Your College or University Enrollment Plans Name of Washington college or university where you will be enrolled during the fall 2015 University of Washington-Tacoma Will you be attending Full-time (12 or more credits each term) Your Eligible Field of Study Select the one field of study that best describes your educational plans. Technology Your Academic Major Select the eligible high-demand STEM or health care major (by alphabet; by category) that best describes your academic plans. Computer Engineering, General
6 Please note: if your specific major is not on this list, you are not eligible to apply. If your plans change in the future and you decide to pursue a major that is not included on the list above, you will be unable to renew your scholarship for future years. When you reach junior class standing (90 quarter credits or 60 semester credits), you will be asked to provide verification from your college that you are pursuing one of the majors listed above. Activities Extracurricular, Personal, and Volunteer Activities List your top three extracurricular, religious, community, family activities and hobbies. Include specific events and/or major accomplishments that would demonstrate your interest in science, technology, engineering, math (STEM) or health care. 1. Activity Name Technology Club, Wilson High School Positions held, honors won, or letters earned Club founder and president Dates of activity from 9/1/2012 To 6/1/2013 Total hours spent on this activity for the timeframe listed above Activity Name Science Tutor Positions held, honors won, or letters earned Tutor at a local high school Dates of activity from 9/1/2014 To 1/5/2015 Total hours spent on this activity for the timeframe listed above Activity Name Track Positions held, honors won, or letters earned Varsity, Captain Dates of activity from 9/1/2011 To 6/1/2013 Total hours spent on this activity for the timeframe listed above 220
7 Work Experience Paid Work Experience/Student Income Information List the top two jobs, (including summer employment), you have held during the past three years. 1. Specific job and nature of work Cashier Employer Target Date of employment from 6/1/2014 To 9/1/2014 Approximate # of hours spent per week Specific job and nature of work Employer Date of employment from To Approximate # of hours spent per week Financial Information Your Free Application for Federal Student Aid (FAFSA) or Student Aid Report (SAR) Information To answer the following questions you will need to have the information from your FAFSA or from your SAR that you receive from the U.S. Department of Education after filing the FAFSA. Reminder, the FAFSA needs to be submitted by the deadline of March 9, 2015 to be considered for this scholarship. Please let us know whether you completed the FAFSA as a dependent or an independent student. (You are a DEPENDENT student if your parent(s) were required to provide financial information when you completed the FAFSA. You are an INDEPENDENT student if your parent(s) were NOT required to provide financial information on the FAFSA.) I completed the FAFSA as: A dependent student The financial information provided below is: From my filed FAFSA Provide the following information on Household Size and Total Family Income as reported on the FAFSA or SAR. 1. Household Size (Dependent students should enter line 73 from the FAFSA/SAR) Adjusted Gross Income (Dependent students should enter line 85 from the FAFSA/SAR) 62,104 Please note: If your parents did not file taxes, you must include any income that was reported by them on the FAFSA/SAR lines 88 and 89.
8 Untaxed Income (Dependent students should enter lines 94a-94i from the FAFSA/SA) 1000 Family income Maximum Family Income Requirements to Apply Please click on "Calculate total annual income for 2014". This is the sum of the adjusted gross income (2), plus any untaxed income (3). Total Annual Income for ,104 Total Family Income (adjusted gross income plus all untaxed income) for 2014 cannot exceed this amount listed in this chart for your family size (entered on line 1). Please note: In order to be eligible, you must have a valid SAR. Essay Essay Instructions A minimum of 150 and a maximum of 300 words are required for the essay question before the application can be submitted. We strongly recommend you do the following: Read the question first Outline your response before you begin writing Write a draft of your essay. If it s easier for you, you can write it in Word and paste it into the box below Share a draft with a teacher or relative Essay Question Washington state is a global leader in many industries such as computer science, engineering, health care, and agriculture. The success of these industries can be attributed to inspirational individuals and leaders. Please tell us why one of these individuals or companies inspires your pursuit of a STEM or health care major at a Washington state college or university, or describe a personal experience that has kindled your interest in the pursuit of a STEM or health care degree. One person who has really inspired me to pursue a degree in computer engineering is my computer science professor. In my introduction to computer science class my freshman year, my professor made sure we understood how important computer engineering is to any industry or situation, to help keep track or information and help businesses run efficiently. I would like to get a degree in computer science because I want to make a difference in helping companies and industries operate more efficiently. I would love to work at Microsoft one day so I can be a part of developing new programs and systems.
9 Instructions to Mail your Transcript Please submit the transcript required based on your current enrollment status: If you have not yet graduated from high school - You must submit an official high school transcript, showing all of your classes through fall quarter/semester 2014 and it must include your cumulative GPA. You may need to request an official transcript from your high school a couple of weeks in advance, so be sure to plan ahead. If you are a Running Start student not graduated from high school yet - You must submit an official transcript from your high school (not college), showing all of your classes through fall quarter/semester Check with your high school to ensure that your Running Start credits for fall quarter/semester are included. You may need to request an official transcript from your high school a couple of weeks in advance, so be sure to plan ahead. If you have graduated from high school and are enrolled in college/university - You must submit an official transcript from your college/university, showing all of your classes through fall quarter/semester 2014 and it must include your cumulative GPA. You may need to request an official transcript from your college a couple of weeks in advance, so be sure to plan ahead. If you have graduated from high school, but have not yet enrolled in college - You must submit an official high school transcript. If you have graduated from high school, attended college, but are not enrolled fall quarter/semester You must submit an official transcript from the college/university where you earned the most credits. It must be up to date, and include your cumulative GPA. If you received your GED and have not yet enrolled in college - You must submit a copy of your official GED score. Please mail your transcript to: College Success Foundation Washington State Opportunity Scholarship 1605 NW Sammamish Rd. Suite 200 Issaquah, Wa Your transcript must be postmarked by Monday, March 9, 2015 and you must have filed the FAFSA by Monday, March 9, 2015 for your application to be considered complete. I will mail my official high school or college transcript to the College Success Foundation by Monday, March 9, I have already filed or will file my FAFSA by Monday, March 9, 2015.
10 How Did You Hear About WSOS? How did you learn about the Washington State Opportunity Scholarship? Please select all that apply. My College/University Student Support Departments (i.e. Student Services, Admissions, Financial Aid, Scholarship Office) I saw a WSOS poster or received a bookmark that advertised the scholarship at my college/university My High School None of the Above/Does Not Apply Friends and Family Members My family Media/Social Media None of the Above/Does Not Apply Online Search None of the Above/Does Not Apply From an Organization Washington Science, Technology, Engineering, Mathematics (STEM) program or network contact Other (please indicate) Agreement/Consent My Pledge of Accuracy, Agreement, and Consent By my electronic signature on this form I promise that: All of the information provided in my application is complete, current and accurate to the best of my knowledge. All of the information I have provided from my Free Application for Federal Student Aid (FAFSA) or from my Student Aid Report (SAR) is complete, current and accurate. By my electronic signature on this form I understand and agree that: The information submitted in this application may be reviewed by the College Success Foundation (CSF) staff, approved consultants, college staff or other approved volunteers for the purposes of selection and/or verification of information provided by me. All information, including but not limited to: GPA, college or university enrollment, program of study, actual or intended academic major, FAFSA household size and FAFSA income information is subject to review or verification by any colleges or universities I may be attending during the period of the scholarship, and by the Washington Student Achievement Council (WSAC) or their successor.
11 If at any time information provided in this application is found to be false or inaccurate, it is sufficient cause for rejection or dismissal from the scholarship program. By my electronic signature on this form I consent to: Authorizing all information now approved for release to be transferred to another organization should another organization other than CSF, the current program administrator, be later named as the program administrator for this scholarship. Authorizing the use of any and all information from this application in connection with CSF research and evaluation activities. This includes my academic or financial information as long as this will not be made available to the public in a form that would allow me to be identified. Stated differently, application information may be made available to the public in an aggregated form, however, such as an average or a total for a group of students. Authorizing any college or university that I may attend while receiving the Washington State Opportunity Scholarship to release to the program administrator (CSF) information including, but not limited to: my academic records, transcripts, program of study, academic major, state residency, financial aid, information from my FAFSA and any other pertinent information needed by CSF, both while I am a student and after I am no longer attending, in order to manage and report on this program. Authorizing the Washington Student Achievement Council, or their successor, and the program administrator (CSF) to share any information received from my FAFSA, my scholarship application, or transcript, for as long as necessary to manage and report on this scholarship. If you are selected for this scholarship, CSF may (1) release your name and the name of the college or university you are attending to interested parties such as news media, school districts, governmental agencies, and legislative personnel for the purpose of recognizing the accomplishments of scholarship recipients, and (2) use my name, picture, or likeness (the Likeness Materials ) for any program or CSF purpose. I waive (1) any rights I may have in connection with use of my information or the Likeness Materials, including any right to own, inspect or approve the form, media or manner of use and (2) any liability resulting from the use of my information or the Likeness Materials. If I am selected as Program participant, I will, upon CSF s request, sign additional releases in form and substance acceptable to CSF. By typing your name below, this will serve as your electronic signature for the agreement/consent section. Applicant Agrees Applicant First Name Jenny Applicant Last Name Smith Month 1-January Day 7 Year 2015 If you are under 18, your parent/guardian needs to sign. I am under 18 No
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APPLICATION FOR EMPLOYMENT City of Los Altos One North San Antonio Road, Los Altos, California 94022 (650) 947-2765 Fax (650) 947-2731 www.ci.los-altos.ca.us AN EQUAL OPPORTUNITY EMPLOYER FOR OFFICE USE
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