College and Career Scholarships, Inc.
Scholarships Request Form
Directions:
1.
2.
3.
Please fill out form completely.
Email to scholarships@achievabledream.org.
Mail or deliver the relevant receipts to An Achievable Dream. You will not be given any future scholarship funds until receipts from previous requests have been
received.
College and Career Scholarships, Inc. agrees to allow your Merit Scholarship to be used for payment of certain college expenses which may subsequently be funded by other
scholarships or awards. Any college expense paid from the Merit Scholarship must be pre-approved by College and Career Scholarships, Inc. The expenses requested for payment
are listed below. If approved for payment, I agree that if any refund is received from the college, or if any funds are received which were intended to cover these expenses, I will
repay College and Career Scholarships, Inc. for these expenses.
Personal Information
Student Name:
College ID Number:
Phone Number:
Email:
HS Graduating Class of:
Scholarship Information
Requested for Semester of:
Total Amount:
Check should be made payable to:
Purpose & Amount of Expense:
Tuition
Books
Room
Other (explain below)
Other Notes/Explanations:
Scholarship check should be mailed to the following address:
Recommended by:
An Achievable Dream Representative
Date
An Achievable Dream, Inc. Approval By:
An Achievable Dream, Inc Representative
An Achievable Dream, 10858 Warwick Blvd, Ste A, Newport News, VA 23601
Office: 757-599-9472 Fax: 757-873-4887
Email: scholarships@achievabledream.org
Date
College and Career Scholarships, Inc.
Scholarships Request Form
School Information
College Attending/Military:
School Phone Number:
School Address:
Major:
Expected Graduation Date:
Cumulative GPA:
Internships:
Recognitions/Awards:
Additional Scholarships Other Than An Achievable Dream:
Income Information
Gross Annual Family Income:
Self Support (No Family Support):
Number in Family:
Yes:
No:
Additional Information
Typing your name below verifies all the above information is correct.
Student Signature
Date
Grades Sent:
Yes
No
An Achievable Dream, 10858 Warwick Blvd, Ste A, Newport News, VA 23601
Office: 757-599-9472 Fax: 757-873-4887
Email: scholarships@achievabledream.org