College of Alameda
Laney College
Date of Application: ____ / ___ / _______
Merritt College
Berkeley City College
Applying for: ____________________________
(Name of one (1) scholarship ONLY)
Master Scholarship Application
Please complete the entire application. Incomplete applications will not be considered. A separate
application must be completed for each scholarship administered by the Peralta Colleges
Foundation. Please attach your unofficial transcripts and 500 word essay to this application.
Make sure your name and student ID number appear on the top of pages 2 - 4. Page 3
(SECTION III: BIOGRAPHICAL DATA & SEPARATE 500 WORD ESSAY) must be typed using
Microsoft Word program. A Microsoft Word version of the master scholarship application is located
on our website http://www.peraltafoundation.org/. Pages 1, 2 & 4 can be completed by printing
legibly (blue or black ink) and/or typed using the master scholarship application on our website. Data
not applicable should be noted as N/A. Information provided is strictly confidential.
SECTION I: PERSONAL DATA
Name: __________________________________________________________________________________
Last
First
Middle
Permanent Address: ______________________________________________________________________
Complete Street Address
________________________________________________________________________________________
City
State
Zip Code
Home Phone Number: ________________________ Cell Phone Number: _________________________
Email Address: _________________________________________________________________________
Date of Birth: ______/______/______
Student ID Number: _________________
Gender:  M  F
US Citizen?  YES  NO
Student’s Name
Student’s ID #
SECTION II: EDUCATIONAL RECORDS & GOALS
High School Diploma  YES  NO
High School _______________________________, _____________
Graduated and/or Recently Attended
City
GED
Graduation Date: ______ / ______
MO
YR
 YES  NO
Peralta Campus Currently Attending:
 Laney College
Number of Units Completed: _______________ Units Enrolled In Current Semester: _____________
 Merritt College
Number of Units Completed: _______________ Units Enrolled In Current Semester: _____________
 College of Alameda
Number of Units Completed: _______________ Units Enrolled In Current Semester: _____________
 Berkeley City College
Number of Units Completed: _______________ Units Enrolled In Current Semester: _____________
(UNOFFICIAL TRANSCRIPT
Grand Total Units Completed: _______________ Cumulative GPA: _________ ATTACHMENT REQUIRED)
Have you ever attended another College or University?  YES  NO
If yes, please list below:
University/College Name: _______________________ Units Completed: ________ GPA: __________
University/College Name: _______________________ Units Completed: ________ GPA: __________
Transferring to 4-Year University:  YES  NO
If Yes, please list below:
University/College Name: _____________________________
Type of Degree:  AA  AS  BA  BS  Certificate of Achievement
Major: ___________________________
(EXPECTED) Year of Completion: ____________
Cert. of Achievement: _________________________ (EXPECTED) Year of Completion: ____________
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PCF Master Scholarship Application Page 2 of 5
Student’s Name
Student’s ID #
SECTION III: BIOGRAPHICAL DATA & SEPARATE 500 WORD ESSAY
Please answer all three (3) questions below on a separate sheet, typed, single-spaced,
using 12-point font Microsoft Word program:
Question #1: Work experience while attending college?
(Please provide employer, position held, employment dates, and hours worked per week)
Question #2: Extra-Curricular Activities?
(Please include exact dates and description of activities)
Question #3: Any awards, honors or recognition received?
(Please list all acknowledgements and exact dates)
SEPARATE 500 WORD ESSAY:
In 500 words or less, please briefly describe what qualifications you have that makes you
deserving of this scholarship. Also, please tell us about your current AND future academic,
career, and personal goals. Essay must be typed, single-spaced, on a separate sheet,
using 12-point font.
Revised 02.11.2013
PCF Master Scholarship Application Page 3 of 5
Student’s Name
Student’s ID #
SECTION IV: FINANCIAL INFORMATION
Must be completed by the Financial Aid Office
Note: Please give this page to the Financial Aid Office, which will complete the form and contact you
when it is ready to be picked up. You must have this form completed before you can
submit your scholarship application. Please make an appointment with the Financial Aid
Office at least two weeks in advance to have this form completed
Is the student eligible for a Board of Governors Fee Waiver?
Yes _____
Has the student received financial aid at any of the Peralta Colleges?
No _____
Yes _____
No _____
If Yes, please list:
Grant: __________________________________________________________________________
Amount Received: __________
Year: ________
Peralta College: _______________________
Grant: __________________________________________________________________________
Amount Received: __________
Year: ________
Peralta College: _______________________
Grant: __________________________________________________________________________
Amount Received: __________
Year: ________
Peralta College: _______________________
All Other aid______________________________________________________________________
Marital Status: Single_______
Married ______
Separated_______
Divorced ______
Number in Household: ______________
Student is:
Independent: ______
Dependent: _____
Student Cost of Attendance:
________________________
Remaining Need:
________________________
The Financial Aid Office must be notified when a student receives a scholarship award.
FAO Certification:
____________________________________________________________________________
Name
Title
Date
Under the California Dream Act (AB 130) students attending a Peralta college who are exempt from paying nonresident tuition under AB 540
are eligible to receive scholarships funded by private donations and administered through the Peralta Colleges Foundation. If the
scholarship(s) for which you are applying requires you to demonstrate financial need, you have several options:
 Provide your most recent tax return or other income verification.
 A letter of recommendation from someone who can also confirm your financial need.
Revised 02.11.2013
PCF Master Scholarship Application Page 4 of 5
Student’s Name


Student’s ID #
Provide proof that you currently receive TANF (Temporary Assistance to Needy Families), SSI/SSP (Supplemental Security
Income), or General Relief. Students must show proof (i.e.,copy of a CA-7 with current or last month’s date, agency verification, etc.)
Complete the Free Application for Federal Financial Aid (FAFSA), if you are eligible to do so.(Strongly recommended)
ALMOST FINISHED! LAST STEP!
Did you remember to…?

Indicate which scholarship for which you are applying for? Each scholarship requires A
SEPARATE APPLICATION.

Fully complete and sign your application form?

Include at least one (1) letters of recommendations and/or references? IF REQUIRED AS PART
OF SCHOLARSHIP CRITERIA TO WHICH YOU ARE APPLYING.

Include an unofficial copy of required transcripts?

Include your Biographical Data & Separate 500 Word Essay?

Include Page 4 of the Master Scholarship Application COMPLETED AND SIGNED OFF BY AN
OFFCIAL FINANCIAL AID OFFICER?
Remember, only fully-completed scholarship applications – those that include the financial
information requested – will be considered for a scholarship. It is the applicant’s
responsibility to make sure the application is fully completed and in compliance with
the scholarship criteria.
Student’s Certification:
I certify that the information contained on this application is true and correct to the best of my
knowledge. I understand that willful omission or falsification may disqualify me as a
scholarship recipient.
Signature: _________________________________________
Revised 02.11.2013
Date: ______ / _____ / _______
MO
DAY
YEAR
PCF Master Scholarship Application Page 5 of 5