Application Deadline: July 15, 2014
Please complete this application to apply for the Autism Recovery Foundation Applied Behavioral Analysis
Graduate Program scholarship.
Name____________________________________________________________________________________
First Middle Last/Family Previous names
Street address_____________________________________________________________________________
City ________________________________State _________Zip _____________Country________________
Home telephone (_____) _____________________ Cell (_____) ________________________
Email address ___________________________________________________________________________
Citizen of the □ United States □ Resident Alien of United States
Resident of which state ___________ Resident of which state __________
Have you applied for admission to an ABA program? □ Yes
If yes, have you been admitted? □ Yes
□ No
□ Waiting to hear
I intend to begin my graduate study
□ Fall Semester □ Spring Semester □ Summer Term Year__________
College/University ________________________________________________
□ Degree Sought
□ On-campus Program
□ BACB Course Sequence Only
□ On-line program □ Off-campus program
College/University___________________________________________________________________________
Graduation date or anticipated ________________________________
Degree received BA _________ BS_________ Other_________

Please list academic and collegiate awards and distinctions you have earned:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
List college/university activities, community organizations and/or volunteer work in which you have participated or currently belong. Please feel free to attach a separate sheet or your resume if additional space is needed or preferred.
Name of Organization or Activity Special recognitions / Awards / Offices held Years of participation
List past and present employment or military service:
Employer Job Title Years employed Special recognition
Please describe (on a separate sheet) any special circumstances that you think would be helpful as we review your scholarship application.
These may include educational disadvantages, financial need, unusual obstacles, or personal circumstances that may have affected your academic performance, extracurricular involvement, or leadership experience in your baccalaureate degree and/or experience in the field of applied behavior analysis.
The information contained within this application is true to the best of my knowledge. I understand that misrepresentation or fraudulent information may be grounds for loss of scholarship funds and repayment. I understand that, in accepting a scholarship from the Autism Recovery Foundation, I give permission to announce my receipt of a scholarship to scholarship donors and University officials. I understand that I may be asked to complete follow-up information on my use of the scholarship funds and possibly attend a reception for the Autism
Recovery Foundation.
______________________________________
Signature
________________________
Date
ABA Graduate Scholarship Committee
Autism Recovery Foundation
401 Groveland Avenue
Minneapolis, MN 55403
612-925-8364
autismrecoveryfoundation.org