Scholarship form

Contact 1

First Name First Name

Last Name Last Name

Email Address Email Address

Preferred phone number Preferred phone number

Street Address Street Address

City City

State State

Zip Code Zip Code

Date of birth Date of birth

Year of study Year of study

Your current or expected field of study Your current or expected field of study

What is your degree objective? What is your degree objective?

Name of the high school you attended or attend if you are an incoming freshman, and cumulative GPA Name of the high school you attended or attend if you are an incoming freshman, and cumulative GPA

Name of the college or university you will be attending in the 2023 - 2024 school year Name of the college or university you will be attending in the 2023 - 2024 school year

If you are not an incoming freshman, please provide your cumulative GPA for the college or university you currently attend. If you are not an incoming freshman, please provide your cumulative GPA for the college or university you currently attend.

List other colleges or universities you’ve attended, degrees earned, and cumulative GPA as appropriate List other colleges or universities you’ve attended, degrees earned, and cumulative GPA as appropriate

What is your long-term career goal? Where do you see yourself in five to ten years? What is your long-term career goal? Where do you see yourself in five to ten years?

Describe extracurricular activities or community service in which you have been or are currently involved. Describe extracurricular activities or community service in which you have been or are currently involved.

Describe the skills and strategies you employ as a blind or visually impaired person to accomplish your goals. Describe the skills and strategies you employ as a blind or visually impaired person to accomplish your goals.

Provide examples of ways in which you’ve demonstrated leadership. This could be in your community, school, place of worship, or as part of a social organization outside the home. Provide examples of ways in which you’ve demonstrated leadership. This could be in your community, school, place of worship, or as part of a social organization outside the home.

Describe what you hope to gain from the experience of attending the Pennsylvania state convention. Describe what you hope to gain from the experience of attending the Pennsylvania state convention.

May we contact you? If so, how? May we contact you? If so, how?

Please indicate whether one of the leaders of the Pennsylvania state student division may contact you, and by what preferred means – email, phone, text. Please indicate whether one of the leaders of the Pennsylvania state student division may contact you, and by what preferred means – email, phone, text.

How did you hear about the NFB of Pennsylvania scholarship program? How did you hear about the NFB of Pennsylvania scholarship program?

Please tell us anything else you think we should know about you in evaluating your application. Please tell us anything else you think we should know about you in evaluating your application.

Feel free to list any awards you have received, experiences that reflect who you are or anything else you think we might find of interest. Feel free to list any awards you have received, experiences that reflect who you are or anything else you think we might find of interest.

Reference 1 Name Reference 1 Name

Reference 1 Affiliation Reference 1 Affiliation

Reference 2 Name Reference 2 Name

Reference 2 Affiliation Reference 2 Affiliation

Reference 3 Name Reference 3 Name

Reference 3 Affiliation Reference 3 Affiliation

Recommendation letters Recommendation letters

Attach any recommendation letters. File extensions may include Doc, Docx, or PDF and may not exceed 2 MB
One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx.

Transcripts Transcripts

One file only.
2 MB limit.
Allowed types: gif, jpg, jpeg, png, txt, rtf, pdf, doc, docx.

Certification statement Certification statement

By typing my full name and the date below, I confirm that all the information provided above and in related attachments is true and correct to the best of my knowledge

Date of affirmation Date of affirmation

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