Category Applying for: _____ Young Starters _____ Juniors _____ Seniors _____ Freshmen

Last Name___________________ First Name___________________ Middle Name____________

Age: _____ Birthday: __________ Gender: __________ Soc. Security: ___________________

Address____________________________ City_____________________ State___ Zip______

Home Phone______________ Work______________ Cell______________

Emergency Contact Name______________ Relation______________ Phone______________
Address____________________________ City_____________________ State___ Zip______

School or College Contact____________________________
City_____________________ State___ Zip______

How many brother and sister do you have? ________

How did you hear about Young Talented Achievers Scholarship Award Program? (Please circle one)

  • Media (Newspaper, TV, Radio)
  • Word-of-mouth
  • Other:_______________________________________________________

    Ethnicity (Circle One)     American Indian/Alaskan Native      Asian      Black/African American
    Hawaiian Native/Other Pacific Islander      Hispanic or Latino    White    Other: _________________

    Applicant Certification: My Signature below indicates that I have been informed of and understand the information contained on this form. I certify under penalty of perjury that all of the above information is true and complete. I agree that any information I have supplied is subject to verification.

    _____________________________________________________________________
    Print Name            Signature of Applicant/Parent/Guardian              Date

    _____________________________________________________________________
    Signature of Interviewer             Interviewer ID                               Date



    Mail Completed Application to:
    Inland Empire Services
    101 Snow Chief Drive
    Havre De Grace, MD 21078
    (800) 731-9567