THOMAS G. LABRECQUE SMART START SCHOLARSHIP PROGRAM A P P L I C A T I O N ATTENTION: PLEASE COMPLETE. HOW DID YOU FIND OUT ABOUT THE PROGRAM? High School Guidance Counselor Current Smart Start Intern Chase Bank Branch Participating College High School College Fair/Visit Other Online Please Explain SMART START PROGRAM CODE 9963
August, 2012 Dear Applicant, The Thomas G. Labrecque Smart Start Scholarship Program awards full-tuition scholarships to students attending Barnard College, Baruch College, Brooklyn College, City College, Columbia University, Fordham University, Long Island University (Brooklyn Campus), New York University, Pace University, Polytechnic Institute of New York University, St. Francis College, and St. John s University. As a candidate, it is necessary that you provide information to the Scholarship and Recognition Program of the Educational Testing Service (ETS). Please read the instructions below carefully, and return the forms by the specified dates. JPMORGAN CHASE THOMAS G. LABRECQUE SMART START SCHOLARSHIP APPLICATION The student should complete all information on pages 1, 2 and 3. If you need more space, you may attach an additional sheet of paper. Your answers to these questions about your background, interests and future plans will be considered in the review process. Once you have completed all of the student sections, please forward the application to your College Advisor or Guidance Counselor so they can complete the SECONDARY SCHOOL REPORT section on page 4 of the application. An official transcript must also be submitted with the application form. A PERSONAL AND a PROFESSIONAL RECOMMENDATION from a teacher, or former employer, must be completed on page 5 & 6. Please allow enough time for your College Advisor and Personal or Professional Recommender to complete their sections. Additionally, pages 7-10 of the application includes Frequently Asked Questions. All application materials are due (postmarked) to the Scholarship and Recognition Program of the Educational Testing Service (ETS) by January 18, 2013. In order to meet the application deadline date, students are advised to take the SATs by December 2012. If the test is taken in December 2012, you must list Smart Start, code 9963, as one of the five recipients of your scores in order to meet the application deadline. FINANCIAL NEED Financial need is a very important factor in the consideration of eligibility for the Thomas G. Labrecque Smart Start Scholarship award. To comply with this requirement a student may file one of two financial aid forms, the CSS Financial Aid PROFILE (PROFILE) or the Free Application for Federal Student Assistance (FAFSA). Please file these forms as soon as they are available. These forms must be filed prior to the deadline of the scholarship, which is January 18, 2013. You can complete the PROFILE application online at www.collegeboard.org. Please use code number 9963. There is a processing fee of $25.00 to file this form. Please refer to their FAQ document to see if you are eligible to have this fee waived. A report of the analysis of this form will be sent to Scholarship and Recognition Programs. You can complete the FAFSA application online at www.fafsa.ed.gov. There is no code number for the Thomas G. Labrecque Smart Start Scholarship Program. You will need to make a copy of your processed form (Student Aid Reports) when they are available and mail them to Scholarship and Recognition Programs. Employment Eligibility In order to qualify for the scholarship, you must meet the employment requirements of the program. Due to the internship component of the award, students must provide proof of eligibility to legally work within the United States. These materials will be reviewed by an independent Scholarship Selection committee comprised of admissions officers from leading colleges and universities. As part of the final selection process, the most qualified candidates or finalists will be recommended to JPMorgan Chase for a personal interview. Winners of the Thomas G. Labrecque Smart Start Scholarship will receive full tuition (less financial aid) for four years (8 consecutive semesters) towards an undergraduate degree at one of the participating colleges, a paid internship at JPMorgan Chase and $750 per year for books. Winners will be notified the last week of April, 2013. Winners must begin working in July, 2013. If you have any questions about the Scholarship or the application process, please review the FAQs at the back of the application or contact us by telephone at 866-520-2976 or via e-mail at Smart.Start@chase.com. We look forward to your participation in the Program and wish you good luck in the competition. PLEASE MAIL YOUR APPLICATION AS WELL AS ANY ADDITIONAL DOCUMENTS TO: Thomas G. Labrecque Smart Start Scholarship Educational Testing Services P.O. Box 6730 Princeton, NJ 08541-6730 Sincerely, Emma Miccio Smart Start Program Manager Telephone: 866-520-2976 Smart.Start@chase.com
THOMAS G. LABRECQUE SMART START SCHOLARSHIP PROGRAM APPLICATION PROGRAM CODE 9963 APPLICANTS MUST BE NEW YORK CITY RESIDENTS GRADUATING FROM A NEW YORK CITY HIGH SCHOOL IN 2013 TO BE ELIGIBLE TO PARTICIPATE IN THE THOMAS G. LABRECQUE SMART START SCHOLARSHIP PROGRAM. SCHOLARSHIP WINNERS MUST HAVE LEGAL AUTHORIZATION TO WORK WITHIN THE UNITED STATES. This questionnaire is designed to collect information about your background, your interests and your college and career plans. Your answers to these questions are confidential and will be reviewed by an independent scholarship selection committee of admissions professionals, as well as JPMorgan Chase Smart Start staff. It is important that your responses to this questionnaire be complete, neat and legible. Wherever possible, please limit your responses to the space provided and TYPE or PRINT, using black ink. Please mail your application to: Thomas G. Labrecque Smart Start Scholarship Educational Testing Services, P.O. Box 6730, Princeton NJ 08541-6730 A. THE APPLICANT LEGAL NAME OF APPLICANT LAST (Please type/print one letter per box) FIRST MI PERMANENT HOME ADDRESS NUMBER AND STREET CITY STATE ZIP CODE BOROUGH SOCIAL SECURITY NUMBER PHONE NUMBER DATE OF BIRTH - - - - B. ACADEMICS 1. HIGH SCHOOL: HIGH SCHOOL NAME BOROUGH 2. I will take the ACT or SAT I on: (PLEASE CHECK ONE) I took the ACT or SAT I on: 3. ARE YOU CURRENTLY A HIGH SCHOOL SENIOR: Check Yes or No MONTH MONTH YEAR YEAR MONTH DAY 5. CHECK OFF SCHOOL(S) APPLIED TO: Barnard College (2038) Baruch College (2034) Brooklyn College (2046) City College (2083) Columbia University (2116) Fordham University (2259) Long Island University (2369) (Brooklyn Campus) New York University (2562) Pace University (2635) Polytechnic Institute of New York University (2668) St. Francis College (2796) St. John s University (2799) YEAR List Codes of Top 3 Choices (in priority order) 4. DATE YOU WILL BEGIN COLLEGE: E-mail Address (if applicable) MONTH YEAR 6. INTENDED MAJOR IN COLLEGE/CAREER CHOICE: (LIFE SCIENCE AND FINE ART MAJORS ARE NOT ELIGIBLE) @ / COLLEGE MAJOR CAREER CHOICE 7. Other than the high school named above, list all schools that you attended in the last three years. List the school you attended most recently first. NAME OF SCHOOL LOCATION (CITY AND STATE) DATES OF ATTENDANCE 8. List any advanced honors, or special academic courses you have taken. List the most recent course or program first. COURSE OR PROGRAM NAME OF SCHOOL LOCATION (CITY AND STATE DATES ATTENDING HRS. PER WEEK PROGRAM CODE 9963 Page 1
C. ACTIVITIES AND WORK EXPERIENCE 1. List activities in which you have participated in your school (such as publications, debate and drama, music, art, sports, student government, and clubs). Include any awards or membership in honorary associations. ACTIVITY DATES OF PARTICIPATION OFFICES HELD SPECIAL AWARDS/HONORS HRS. PER WEEK 2. List volunteer activities in which you have participated without pay, e.g. community service. KIND OF WORK NAME OF AGENCY OR ORGANIZATION DATES OF PARTICIPATION SPECIAL AWARDS HRS. PER WEEK 3. List jobs and internships you have held in the past four years. CHECK ONE: JOB AND KIND OF WORK EMPLOYER SUMMER SCHOOL YEAR APPROXIMATE DATES OF EMPLOYMENT APPROXIMATE NO. OF HOURS PER WEEK D. ACADEMIC/PERSONAL ACHIEVEMENT Of your academic and personal experience, describe the one that gave you the feeling of greatest achievement or personal pride. E. TEAM PROJECT (e.g. class project, extra-curricular or community activity) 1. Describe a team project in which you participated. 2. What did you learn about yourself during your participation in the project? 3. What did you learn about your teammates? Page 2 PROGRAM CODE 9963
F. ESSAY (PLEASE ATTACH EXTRA PAPER IF NECESSARY) In the spaces below, please complete your statement on Why I chose my college major/area of study and how I plan to apply it to my career goals after graduation from college. I understand that it is my responsibility when completing the score report section of my SAT I or ACT registration form to enter Code Number 9963 (Thomas G. Labrecque Smart Start Scholarship Program) as one of the colleges or scholarship programs to which my scores are to be released, or if I have already registered for or taken the SAT I or ACT and did not specify Code Number 9963 as a score recipient, it is my responsibility to file an Additional Report Request Form with the College Board Admissions Testing program to release my SAT scores or file an Additional Score Report Form with the American College Test to release my ACT scores. All tests must be completed by December, 2012 in order to meet the application deadline. I certify that each of the answers given in this application is complete and true to the best of my knowledge. I understand that it is my responsibility to ensure that my school releases any required forms, official transcript(s) of my grades, and any information requested on this application before the program deadline. In accordance with the Family Educational Rights and Privacy Act of 1974, I hereby authorize my high school to release the secondary school record and any other requested information for consideration in the program. I represent that (1) I am not a legal dependent of a JPMorgan Chase employee; and (2) I am legally authorized to work in the United States. I understand that my enrollment in the Thomas G. Labrecque Smart Start Scholarship Program is contingent upon satisfying the employment criteria of JPMorgan Chase. STUDENT S SIGNATURE DATE PARENT S OR LEGAL GUARDIAN S SIGNATURE DATE PROGRAM CODE 9963 Page 3
SECONDARY SCHOOL REPORT TO BE COMPLETED AND RETURNED BY SCHOOL OFFICIAL NOTE FOR SCHOOL OFFICIAL The student named above is an applicant for the Thomas G. Labrecque Smart Start Scholarship. To process the application, we need a character and ability estimate, a transcript of the student s secondary school record, and a school profile. This information will be used only in connection with the selection of scholarship recipients and will be seen by persons involved in the selection process. If the transcript is not provided, the student will not be eligible for consideration in the program. This report should be signed by the evaluator at the bottom of page 4. Complete information should be given wherever possible. Please type or print in black ink. SCHOOL NAME CITY STATE ZIP CODE SCHOOL OFFICIAL S NAME PLEASE PRINT NAME TITLE TELEPHONE EMAIL ADDRESS SECONDARY SCHOOL CODE NUMBER A. STUDENT S ACADEMIC STATUS 1. Is this student a senior at your high school? YES NO 2. CLASS RANK CLASS SIZE STUDENT S CLASS RANK NUMBER OF STUDENTS IN CLASS 3. GRADE POINT AVERAGE. GPA SCORE NUMBER OF SEMESTERS 4. GRADE POINT SCALE. 5. SAT SCORE ACT SCORE MATH WRITING CRITICAL READING CERTIFICATION BY DESIGNATED ADMINISTRATOR Note: Please attach to this form an official and most recent transcript of grades and a high school profile. Failure to provide the transcript will disqualify the student from the scholarship program. SIGNATURE DATE Page 4
PROGRAM CODE 9963 PERSONAL RECOMMENDATION B. HOW WOULD YOU RATE THE STUDENT S ABILITY TO DEMONSTRATE: (PLEASE ATTACH EXTRA PAPER IF NECESSARY) Excellent V. Good Good Fair Poor 1. PROFESSIONALISM: (Holds himself/herself to the highest standards of performance, gets the job done right and on time, takes action to sharpen talents, skills and knowledge). Please cite specific examples: 2. TEAMWORK: (Asks for help when appropriate from whoever is best able to provide it, shows respect for the opinion of others). Please cite specific examples: 3. INITIATIVE: (Is innovative and creative, searches for opportunities to add value). Please cite specific examples: 4. RESPECT FOR OTHERS: (Shows sensitivity to the needs of others, listens to what is said even when he/she disagrees). Please cite specific examples: 5. LEADERSHIP: (Assumes lead role to see project/activity to completion, able to motivate others and assumes responsibility). Please cite specific examples: 6. ABILITY TO BALANCE SCHOOL/WORK/VOLUNTEER ACTIVITIES: (Able to handle multiple tasks without compromising quality, able to prioritize and meet deadlines). Please cite specific examples: 7. Please describe any academic, employment, and community distinctions which the applicant has achieved (e.g., Class or Organization Officer, Fund Raising, Chairperson or Participant). 8. Has the applicant shown exceptional qualities or performed any special services which you feel should be noted? CERTIFICATION BY PERSONAL RECOMMENDATION: Name: Date: School/Company Affiliation: Title: Address: Signature: _ Page 5 PROGRAM CODE 9963
PROFESSIONAL RECOMMENDATION B. HOW WOULD YOU RATE THE STUDENT S ABILITY TO DEMONSTRATE: (PLEASE ATTACH EXTRA PAPER IF NECESSARY) Excellent V. Good Good Fair Poor 1. PROFESSIONALISM: (Holds himself/herself to the highest standards of performance, gets the job done right and on time, takes action to sharpen talents, skills and knowledge). Please cite specific examples: 2. TEAMWORK: (Asks for help when appropriate from whoever is best able to provide it, shows respect for the opinion of others). Please cite specific examples: 3. INITIATIVE: (Is innovative and creative, searches for opportunities to add value). Please cite specific examples: 4. RESPECT FOR OTHERS: (Shows sensitivity to the needs of others, listens to what is said even when he/she disagrees). Please cite specific examples: 5. LEADERSHIP: (Assumes lead role to see project/activity to completion, able to motivate others and assumes responsibility). Please cite specific examples: 6. ABILITY TO BALANCE SCHOOL/WORK/VOLUNTEER ACTIVITIES: (Able to handle multiple tasks without compromising quality, able to prioritize and meet deadlines). Please cite specific examples: 7. Please describe any academic, employment, and community distinctions which the applicant has achieved (e.g., Class or Organization Officer, Fund Raising, Chairperson or Participant). 8. Has the applicant shown exceptional qualities or performed any special services which you feel should be noted? CERTIFICATION BY PROFESSIONAL RECOMMENDATION: Name: Date: School/Company Affiliation: Title: Address: Signature: _ Page 6
THOMAS G. LABRECQUE SMART START SCHOLARSHIP FREQUENTLY ASKED QUESTIONS If you have questions concerning the receipt of your application, or to check the status of your application, please contact ETS at 609-771-7878. QUESTIONS 1. Where can I find the application? 2. Can I still apply if I live just outside of New York City (e.g., Westchester, Long Island, etc.)? 3. I am currently a college student; am I eligible to receive this scholarship? 4. Can I defer my offer of admission for a year? 5. I have issues accessing my online application, what should I do? If I forgot the password to my online application, how can I retrieve it? 6. If I fill out the online application, do I still have to mail documents to ETS? 7. How do I demonstrate financial need? 8. How do I send a copy of my FAFSA to Smart Start? 9. What if I file my FAFSA by the application deadline but do not receive my completed SAR until after the deadline? 10. What is Smart Start s code for the CSS profile? 11. If I took the ACT instead of the SAT, can I submit those scores instead? What if I took both? 12. Do I need to submit my test scores using the score forwarding service on CollegeBoard.com/ACTStudent.org or can I print out the scores and mail them in myself? 13. To what address should I mail supplementary materials? 14. When is the application due? Are exceptions made for late applications? 15. I submitted my application. Can you confirm that all of my materials have been received? 16. What does the scholarship award cover? 17. How many winners are chosen? 18. When do winners hear back from Smart Start? 19. What qualifications does a candidate need to possess? 20. How should my guidance counselor respond if my school does not give out a GPA or only gives letter grades? 21. My school does not provide rankings for its students; how should my guidance counselor note this? 22. I have not received responses from colleges yet. Can I still apply to Smart Start? 23. Can I still apply to the program if I was accepted into the Macaulay Honors Program at a participating CUNY school? 24. What can I major in if I become a Smart Start Scholarship Recipient? 25. If I am a part of the Smart Start program, will I be able to take part in a study abroad program while in college? 26. What is the best way to get in contact with the program if I have any issues or questions? Page 7
ANSWERS 1. Where can I find the application? You may find the Smart Start Scholarship application online at http://www.jpmorgan.com/pages/smartstart/ny. The website will provide you with the option of filling out an online application or a paper application. Many applicants download the paper application and write out their responses first, before submitting it online. You do not need to send a paper-copy of the application if you have filled it out online. There is no preference between the online version and paper version. 2. Can I still apply if I live just outside of New York City? No, the Smart Start program only accepts applicants who both live AND attend school in New York City, which only includes the five boroughs. The scholarship does not include Nassau or Suffolk County, Westchester, or any other part of New York State. It also does not include New Jersey, Pennsylvania, Connecticut, or any other surrounding area of New York City. 3. I am currently a college student; am I eligible to receive this scholarship? No, only current high school seniors may apply for the scholarship. Applications from current college students will not be considered. 4. Can I defer my offer of admission for a year? No, offers of admission cannot be deferred. In order to participate in the program, you must plan to begin your undergraduate studies in the fall immediately following your completion of high school. 5. I have issues accessing my online application; what should I do? If I forgot the password to my online application, how can I retrieve it? If you are having issues accessing your online application because of technical difficulties, please contact the Educational Testing Services (ETS) Scholarship and Recognition Program to resolve at (609) 771-7878. If you ve forgotten your password, you will need the following information in order to retrieve it: Your User Name The answer to the Secret Question you provided when you created your SRP account If you did not enter an e-mail address when you stored your application, or have forgotten your User Name or the answer to your Secret Question, please contact ETS at (609) 771-7878. 6. If I fill out the online application, do I still have to mail documents to ETS? The online application is a two-step process. The first step is completing the application online. The second step is mailing in your financial information, recommendation, and guidance counselor form. Please be aware that you should be working on both steps at the same time in order to submit your application on time. All materials, both on-line and supplementary, must be submitted by the official deadline. 7. How do I demonstrate financial need? To comply with this requirement, a student may file one of two financial aid forms, the CSS Financial Aid PROFILE (PROFILE) or the Free Application for Federal Student Assistance (FAFSA). a. You can complete the PROFILE application online at www.collegeboard.org. Please use code number 9963 for New York or code number. There is a processing fee of $25.00 to file this form. Please refer to their FAQ document to see if you are eligible to have this fee waived. A report of the analysis of this form will be sent to Scholarship and Recognition Programs. b. You can complete the FAFSA application online at http://www.fafsa.ed.gov/. There is no code number for the Thomas G. Labrecque Smart Start Scholarship Program. You will need to make a copy of your processed form (Student Aid Reports) when they are available and mail them to ETS postmarked by the due date. ** Please note if your parents have not filed this year s tax returns, they may complete the forms by using last year s tax returns. These forms usually take from two days to a week in order to be processed and completed. Please begin working on them along with the rest of your application for a timely submission of the Smart Start Scholarship Application. 8. How do I send a copy of my FAFSA to Smart Start? As per the application instructions, you must print out a physical copy of the completed FAFSA and mail it along with the other supplementary materials to ETS: Thomas G. Labrecque Smart Start Scholarship Educational Testing Services P.O. Box 6730 Princeton, NJ 08541-6730 Page 8
9. What if I file my FAFSA by the application deadline but do not receive my completed SAR until after the deadline? You can print out and mail in your SAR once you have received it even after the application due date, as long as the FAFSA was actually filed on or before the due date. 10. What is Smart Start s code for the CSS profile? The code number is 9963 for applicants in New York City. 11. If I took the ACT instead of the SAT, can I submit those scores instead? What if I took both? Smart Start requests that all relevant test scores (SAT/ACT) be submitted. If you took either the SAT or the ACT, those scores will be sufficient. If you took both, please submit both sets of scores. 12. Do I need to submit my test scores using the score forwarding service on CollegeBoard.com/ACTStudent.org or can I print out the scores and mail them in myself? You will need to go through CollegeBoard.com/ACTStudent.org to submit your scores to Smart Start. We do not accept print-outs of score reports. 13. To what address should I mail supplementary materials? All supplementary materials including recommendations must be mailed to: Thomas G. Labrecque Smart Start Scholarship Educational Testing Services P.O. Box 6730 Princeton, NJ 08541-6730 14. When is the application due? Are exceptions made for late applications? Applications are due on January 18, 2013 and should be postmarked by this date. The Smart Start Scholarship Program and ETS do not accept late applications and no exceptions are made. Late applications include those postmarked after the due date and those who are incomplete. Financial information, recommendations and guidance counselor forms are all needed by the due date. 15. I submitted my application. Can you confirm that all of my materials have been received? In order to confirm receipt of application, contact ETS at 609-771-7878. 16. What does the scholarship award cover? The Thomas G. Labrecque Smart Start Scholarship Award covers full academic tuition and a $750 book stipend per academic year. The scholarship does not include room and board or housing costs. The scholarship also includes a 4-year paid internship with JPMorgan Chase. This internship is required of all students. Although candidates are not required to possess U.S. citizenship, all students must be able to demonstrate that they can legally work in the United States. 17. How many winners are chosen? 10 winners will be offered a place in the scholarship program. 18. When do winners hear back from Smart Start? Students will receive offers of admission in the program in or before the last week of April. 19. What qualifications does a candidate need to possess? The program is looking for students who possess the following qualities: Financial aid based on Expected Family Contribution, Academic Achievement, Motivation, Flexibility, Maturity, Initiative, Leadership, Communication Skills, and Ability to balance numerous priorities. Well-rounded individuals usually have better applications since most applicants meet all the eligibility requirements. 20. How should my guidance counselor respond if my school does not give out a GPA or only gives letter grades? Your guidance counselor should try to convert your grade to a GPA scale. It is very important that your guidance counselor provide this information because the GPA will help determine whether you are eligible for the scholarship or not. Page 9
21. My school does not provide rankings for its students; how should my guidance counselor note this? Instruct your guidance counselor to specify that your school does not provide rank on the required guidance counselor s form. This will not count against you or hurt your chances of being selected for the program in any way. 22. I am applying to one or more of Smart Start s participating schools but have not heard back from any of them yet. Can I still apply to Smart Start? The timeframe of Smart Start s application process is parallel to the college application process. As long as you have applied to at least one participating school, you can apply to the program. If, however, you are offered the scholarship and have either not been accepted into any of the participating schools or have chosen to attend school elsewhere, the scholarship offer will be rescinded. 23. Can I still apply to the program if I was accepted into the Macaulay Honors Program at a participating CUNY school? Yes. 24. What can I major in if I become a Smart Start Scholarship Recipient? Students are allowed to major in any discipline except for Life Sciences and Fine Arts. This includes double majors or minors within these fields. a. Life Sciences include the following majors: Agriculture, Bio-engineering, Biochemistry, Biology, Biomechanics, Botany, Ecology, Environmental Science, Genetics, Health Sciences, Immunology, Medicine, Neuroscience, Oncology, Optometry, Pharmacology, Physiology, Plant Sciences, and Zoology. b. Fine Arts include the following majors: Illustrative/Conceptual Arts, Comics, Calligraphy, Photography, Film, Sculpture, Dance, Theatre, Architecture, and Graphic Design. The Smart Start Scholarship Program does not expect its students to be business majors. Some non-business disciplines that students have pursued include history, language, sociology, psychology, political science and pre-law. 25. If I am a part of the Smart Start program, will I be able to take part in a study abroad program while in college? Yes. About half of all members of the Smart Start program choose to study abroad at some point during their college careers. 26. What is the best way to get in contact with the program if I have any issues or questions? The best way to get in contact with the program is via email at smart.start@chase.com. Another way to get in contact with the program is leaving a voicemail with our automated system at 866-520-5976. If you have questions concerning the receipt of your application, or to check the status of your application, please contact ETS at 609-771-7878. Page 10
VOLUNTARY DATA COLLECTION Statement of Purpose: The following self-identification information is requested on a voluntary basis to assist in JPMorgan Chase s compliance with reporting obligations under Federal Equal Employment Opportunity laws and regulations and JPMorgan Chase s affirmative action efforts. Submission of this information is completely voluntary and refusal to provide such information will not subject you to any adverse treatment. No notations should be made on any application form with regard to information supplied on this form. Information obtained shall be kept confidential and used in accordance with Federal Equal Employment Opportunity laws and regulations and JPMorgan Chase s affirmative action efforts. If you do not choose to identify yourself, necessary identifications will be made by visual survey. Group Identity BLACK (Not of Hispanic Origin) ASIAN/PACIFIC ISLANDER (Far East, Southeast Asia, Indian Sub-Continent or the Pacific Islands) WHITE (Not of Hispanic Origin) AMERICAN INDIAN OR ALASKAN NATIVE (Must maintain cultural identification) HISPANIC (Puerto Rican, Cuban, Dominican, Mexican, Central/South American, of Spanish origin) SEX FEMALE MALE DISABLED Yes No If you have an impairment (physical or mental) which substantially limits one or more of your major life activities. (A major life activity is mental or physical function which, if impaired, creates a substantial barrier to employment.) If you have a record of such an impairment. Or, if society regards you as having such an impairment. PLEASE MAIL YOUR APPLICATION TO: Thomas G. Labrecque Smart Start Scholarship Educational Testing Services P.O. Box 6730 Princeton, NJ 08541-6730 Page 11