APPLICATION FORM

Verner E. Suomi Scholarship Award

NAME_______________________________________BIRTHDATE____/____/____SEX:M____F____

HOME ADDRESS:

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HOME TELEPHONE (area code):_____________________Soc. Sec. # (Optional):_________________

EMAIL:________________________________

ETHNIC BACKGROUND (Optional):

European___African-American___Hispanic___Native American___Other (indicate)______________

REFERRING TEACHER/PRINCIPAL/COUNSELOR:

NAME:____________________________________TITLE:____________________________________

HIGH SCHOOL NAME:_______________________________________________

ADDRESS: ______________________________________________________

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PHONE NUMBER:___________________________________________

EMAIL:____________________________________

QUESTIONS REGARDING ELIGIBILITY:

1. When do you expect to graduate from High School? _________________

2. Have you applied for admission to a University of Wisconsin System school? Yes No

3. Name of campus(es) to which you have applied:

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4. Intended Major:_____________________________

5. ACT/SAT Test Scores are available at the following UW Admissions Office:

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SIGNATURE OF PARENT/GUARDIAN:___________________________________ Date _________

SIGNATURE OF APPLICANT:___________________________________________ Date _________


Back to Suomi Scholarship Page listing eligibility, complete application requirements, and deadline.