Fayetteville State University
Freshman
Scholars Program Application
(PLEASE PRINT)
STUDENT INFORMATION
Name_______________
Social Security #______ -____________________ Sex_________
Home Address_________________________________________
(Street)_______________________________________________
(City) (State) (Zip Code)______
Phone # County Date
of Birth____
Ethnic Group___ B=Black; W=White;P-Pacific
Islander/Asian;
I=American;
Indian/Alaskan Native; O=Other
School Currently Attending:_______________________________
Current Grade (1993-94):_________________________________
FAMILY INFORMATION
Father/Guardian: Name__________________________________
Address_______________________________________________
Occupation____________________________________________
Social Security #________________________________________
Education Background: Years Completed (Please Circle)
High School 1 2 3 4 College 1 2 3 4
High School Attended____________________________________
Diploma: Yes o No o
College Attended_______________________________________
Degree: Yes o No o
Mother/Guardian: Name__________________________________
Address_______________________________________________
Occupation____________________________________________
Social Security #________________________________________
Education Background: Years Completed (Please Circle)
High School 1 2 3 4 College 1 2 3 4
High School Attended____________________________________
Diploma: Yes o No o
College Attended_______________________________________
Degree: Yes o No o
ADDITIONAL INFORMATION
Total Family Income $___________________________________
CERTIFICATION: The above information is true & complete to the best
of my knowledge if asked by an authorized official, I agree to give proof
of the above information. I
understand that proof may include a copy of U.S. State or local income tax
returns.
Student Signature/Date__________________________________
Parent/Guardian/Date___________________________________