2013-2014 Stanley H. Black Memorial Scholarship of the Jewish Community Foundation of Los Angeles
Grant Opportunity for Students of UCLA Henry Samueli School of Engineering and Applied Science
(Please print neatly or type)
UCLA ID# (9 digits):
LAST 4 DIGITS OF SOCIAL SECURITY NUMBER:
LAST NAME:
TELEPHONE:
FIRST NAME:
EMAIL ADDRESS:
MAILING ADDRESS:
CITY:
STATE:
ZIP CODE:
DATE OF BIRTH (MM/DD/YYYY):
US CITIZEN:
TERM ADMITTED TO UCLA:
YES
NO
TERM ADMITTED TO HSSEAS:
CLASS LEVEL:
MAJOR:
OPTION (if applicable):
EXPECTED DEGREE COMPLETION TERM/YEAR (e.g. Spring 2014):
Cumulative Grade Point Average (i.e. 4.000):
Verification by Academic Counselor at HSSEAS: Please obtain signature from an Academic Counselor to verify
your GPA at Office of Academic and Student Affairs Henry Samueli School of Engineering and Applied Science
6426 Boelter Hall. Applications without verification will be deemed incomplete.
Academic Counselor Name (please print):
Counselor Signature:
Date:
YES
NO
Are you receiving financial aid for this academic year?*
If Yes, please indicate how much you are receiving from the following:
Grants/Scholarships (i.e. $250.00)
Loans/Work Study (i.e. $250.00)
*If you are currently receiving financial aid please note awarding of additional scholarships
may impact your financial package including grants and other scholarships.
Page 1 of 3
You MUST attach the following three items with this application form:
1. AUTOBIOGRAPHICAL STATEMENT (A well written 1-2 page essay discussing your career
goals, research experience, engineering related internships and/or work experience, and your
involvement in service & leadership, including within the Jewish community.)
2. LIST OF EXTRA-CURRICULAR ACTIVITIES (MUST use same format as sample on page 3)
3. RESUME or CV
Current Date:
Eligibility Form



Undergraduate Engineering Student
GPA of 3.0 or higher
Involvement in service & leadership, especially within the Jewish community
I understand that if awarded a scholarship, I am required to maintain eligibility based on the listed
criteria. I further understand that changing my major or a significant drop in my GPA will affect my
eligibility and could result in the Dean of Academic & Student Affairs or Scholarship Sponsor to
withdraw any award received.
Student Name (please print full legal name):
Date:
STUDENT'S SIGNATURE
DEADLINE: TUESDAY, JANUARY 7, 2014, 5:00 p.m.
Applications available online at: http://www.jewishfoundationla.org/stanley-black-memorial-scholarship
Submit completed applications, including scanned GPA verification signatures to
marypat@jewishfoundationla.org or call (323) 761-8705 for more information
Page 2 of 3
SAMPLE FORMAT FOR EXTRA-CURRICULAR ACTIVITIES RECORD
MUST USE THIS FORMAT!!!
(May use word or excel as long as you use the format below.
Please list most current first!)
LAST NAME: BRUIN
FIRST NAME: JOE
UID: 000111222
PERIOD
February 2012- March 2013
(1 year)
ORGANIZATION
September 2012- September 2013
(1 year)
Jewish Student
Union
Bruin Engineers
Page 3 of 3
POSITION
Social Committee
Chair
Community
Outreach Director
DUTIES/ACTIVITIES
Organized meetings to plan
promotional events
Organized and facilitated
educational, community service
and intercultural programs to
serve the Jewish community and
the campus at large