Scholarship Application
Please read Eligibility and Criteria before proceeding with this form. All fields require content input

Choose the scholarship you are applying for: Jesse Jackson Fellows Cirilo A. McSween (New York Life) Ora Lee Sanders Scholarship
Applicant’s Full Legal Name:
First Name	Middle Name	Last Name
Gender: Male   Female
Date of Birth: Month January February March April May June July August September October November December  Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  Year ex. 1986
Social Security Number:
Race/Ethnicity: (You may only check one, even if you identify with more than one of these groups) African American American Indian/ Alaska Native Hispanic American Asian Pacific Islander American Other
Permanent Home Address (No P.O. Boxes):       Street Address                                Apt. #
City	State	Zip Code
Country
Phone Numbers: (area code first; no dashes or spaces)
Permanent		Alternate
Email Address:
Student		Parent/Guardian
Current School:
School Name		Phone Number
Legal Status - US Citizen: Yes  No
Educational Information: College/University Attending or have been accepted to
Address
City	State	Zip Code
Major		Minor
Incoming Year Classification Status:	Freshman Sophomore Junior Senior
Anticipated Graduation Date:	/ (MM/YYYY) ex. 06/2004
Cumulative GPA: (4.00 Scale)	SAT Score:	ACT Score:
Essay (min. 500 words; copy/paste from text or word document) Identify five prerequisites for success and explain in detail your personal philosophy for the pursuit of excellence.  Explain how you will use your college education to achieve this pursuit of excellence.
Letters of Recommendation will be sent by: Letter #1 Letter #2
Are you a member of Rainbow/PUSH? Yes  No
I hereby certify the information provided in this application is, to the best of my knowledge, true and correct. I have not knowingly withheld any facts that would jeopardize consideration of this application, and can provide documentation to prove I am legally authorized to work in the United States. RainbowPUSH and PUSH Excel may use all information obtained from my entry for marketing purposes.
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