Urban League of Rochester Salute to Black Scholars Program
Submit and update as often as necessary
Generic (Supplemental) Scholarship Application Form
This application is used for scholarships on the Urban League of Rochester Black Scholars Scholarship List that do not have a
separate application.
To be considered for these scholarships or awards, you must:
1. Return this form with your essay(s)
2. High school transcript to the Black Scholars Office.
3. Include a copy of your high school transcript for each opportunity/application you want to be considered for.
4. Include three letter of references.
Senior grades will be required for 2nd marking period or 3rd for schools with six marking periods. Make sure E-mail
address and your cell phone numbers are included.
YOU MUST SUBMIT THE ORGANIZATION’S APPLICATION TO BE CONSIDERED FOR THEIR AWARD WHERE
APPLICABLE.
Complete the following:
Name: ___________________________________________________ SSN :_(last 4 digits)- _____________ Gender___________
First
Last
Home Address ____________________________________________ County___________________ Home Phone_______________
City_________________________________________ State_______ Zip Code____________ E-mail__________________________
High School________________________________________________ School Phone______________________________________
Address________________________________________________ City____________________________ Zip _____________
Graduation Year______________ Grade Point Average ________/________ Rank in Class_____________ Class Size___________
(Un (weighted/weighted GPA)
Aptitude Test:
ACT Composite Score______________ or SAT Scores: Verbal _______Math ________Writing________ Total _________
(Please submit copy of test scores to us)
Intended major(s) or interest area(s) is/are (please list in order of preference):
First choice__________________________________________ Second choice _____________________________________
Long Range Career Goal (i, e. Lawyer, Business Owner, etc)_______________________________________________________________________
College: List the colleges you have applied or intend to apply. (Use a separate sheet if necessary.
First _________________________________________________________
Application status a – applied b – intend to apply
_____________________________
Second ________________________________________________________
_____________________________
Third ____________________________________________________
____________________________
Parent/Guardian
Mother’s Name________________________________________ Father’s Name _________________________________
Financial Information:
(Total gross family income) We are no longer requesting this information, but be aware most scholarship givers may require
a SAR (Student Aid Report) as part of the documentation before making any final selections. Please complete FAFSA form in
a timely manner.
Number of dependent brothers/sisters living at home ________Number currently attending college _________ as of______________
Salute to Black Scholars Program
265 North Clinton Avenue
Rochester, New York 14605
(585) 325-6530, x 3082 or 3088
Fax: (585) 325-4864
E-mail: annette.rouse@ulr.org
Urban League of Rochester Salute to Black Scholars Program
Submit and update as often as necessary
Please list sources of financial aid (including other scholarships, loans, grants received and/or applied for). Attach separate sheet, if
needed.
Financial Aid Source
List on separate sheet of paper and update as needed
__________________________________________________________
Applied for
Received
___________
________
Financial Information Continued
What will you do to bridge any “financial gaps” to fund your education? ____________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Personal Achievements: You may attach a resume in lieu of I, II, III, IV, and V.
I.
Extra-curricular Activities or Office Held
Year
Position Held
__________________________________________________________
_______
________________________
__________________________________________________________
_______
________________________
__________________________________________________________
_______
________________________
__________________________________________________________
_______
________________________
__________________________________________________________
_______
________________________
__________________________________________________________
________
________________________
__________________________________________________________
________
________________________
IV.
Awards
_________________________________________________________
________
_________________________
__________________________________________________________
________
__________________________
__________________________________________________________
________
__________________________
II.
III.
V.
Community Service
Employment
References: List three (3) references and their relationship to you (teacher, employer, clergy, coach, and counselor).
(Submit letters of recommendations/references with application)
_____________________________________________________________
_________________________________
_____________________________________________________________
_________________________________
_____________________________________________________________
_________________________________
Essay: Please write a short essay describing your background, career goals, objectives, and other experiences that have contributed to your personal
development and future aspirations. Use a separate sheet. Essay should not exceed 350 words.
SUBMIT COMPLETED FORM TO: Black Scholars Office, Urban League of Rochester, 265 North Clinton Avenue, Rochester, NY 14605;
phone (585) 325-6530, ext 3082; or e-mail Ms. Annette Rouse, Coordinator at annette.rouse@ulr.org.
Please return this complete application with a copy of your latest high school transcript.
Applicant signature ____________________________________________________________Date ___________________________________
Salute to Black Scholars Program
265 North Clinton Avenue
Rochester, New York 14605
(585) 325-6530, x 3082 or 3088
Fax: (585) 325-4864
E-mail: annette.rouse@ulr.org
Urban League of Rochester Salute to Black Scholars Program
Submit and update as often as necessary
Salute to Black Scholars Program
265 North Clinton Avenue
Rochester, New York 14605
(585) 325-6530, x 3082 or 3088
Fax: (585) 325-4864
E-mail: annette.rouse@ulr.org