2010-2011 Academic Year Application
Application Deadline: July 15, 2010
Student Name:_____________________________________________________________
(Last) (First) (M.I.)
Home Address: ____________________________________________________________
Street: ____________________________________________________________________
City ________________________________State: _______________ ZIP:_____________
E-mail Address: ____________________________________________________________
Name of High School : ______________________________________________________
Date of Graduation:_________________________________________________________
Class Rank:__________________ GPA:______________________
Special Awards, Honors, or Activities: _________________________________________
(Attach additional sheet if necessary)
2009 Family Income:________________________________________________________
PASSHE university you plan to attend: ________________________________________
Major: ___________________________________________________________________
I declare that the information provided herein is true and correct to the best of my
knowledge. I also give permission to release my name and photograph to the
Scholarship Committee and to the PASSHE Foundation for promotional purposes.
____________________________________ ___________________________
Signature of Scholarship Applicant Date
Please include the following with your completed application:
- Your five-hundred to eight-hundred word essay on the following topic: How this scholarship will help you
achieve your education and career goals.
- The completed application.
Deadline for submission is July 15, 2010, to:
Eileen Showers
Director of Scholarship Programs
PASSHE Foundation
2986 North Second Street
Harrisburg, PA 17110
