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UALR Academic Scholarship Form



This form must be filled out completely to be considered for an Academic Scholarship.

By submitting this application and required credentials, you will be considered for the UALR–funded academic scholarships in which you are eligible. We strongly recommend that you also complete and submit the Free Application for Federal Student Aid (FAFSA) at www.fafsa.gov to be considered for need-based aid.

Note: This application is NOT used for the International Award.

Personal Information - Required Section

Student Name (Last, First, Middle):

UALR ID Number or Last 4 digits of Social Security Number:

Date of Birth (MM/DD/YY):

Address:

City: State: Zip:


Home Telephone (including area code):

Work or Cell Telephone (including area code):

E-mail:

Citizenship: US Citizen Permanent Resident Alien

Did you participate in EAST in high school? No
Yes If yes, how many years

Anticipated UALR Academic Major:

UALR Classification:
Freshman
Sophomore
Junior
Senior
Other

Ethnicity:   Gender:Male Female

ACT/SAT: Class Rank/Gpa: GED Score:

Semester to Start at UALR: FallSpring
Year to start at UALR:

Name of High School:
Year Graduated:

Previous College Information - Required Section

Please list all previous college information(indicate NONE if never enrolled at another college).

Previous College Information - Required Section
College Attended Year(s) Hours
Earned		 Hours Currently
Enrolled		 GPA

Required Section - Donaghey Scholars Program, Chancellor’s Leadership Corps, Science Scholars, and EAST Scholars

In each category, list the most recent experience or award first, covering the past five years. When indicating dates, please specify months and years.

Community Service and Volunteer Work
Community Service/Volunteer
Organizations		 Dates
of service		 No. of
Hours		 My Role and Contribution
from:
to:
from:
to:
from:
to:
from:
to:
from:
to:

Activities and Clubs
Activity or Club Dates No. of
Hours		 My Role and Contribution
from:
to:
from:
to:
from:
to:
from:
to:
from:
to:

Honors and Awards
Honor or Award Reason for Award Date Awarded

Employment Information
Employer Dates No. of
Hours perWeek		 My Title and Position Description
from:
to:
from:
to:
from:
to:
from:
to:

All the information I have provided is correct to the best of my knowledge. By signing this application, I authorize the University of Arkansas at Little Rock to furnish copies of my academic record, this application, faculty and/or personal letters of recommendation and information regarding my financial need, when appropriate, to scholarship donors or their designated representatives and any scholarship committees for review in considering my application for any scholarship for which I may be eligible. I hereby give my permission to UALR to issue a news release if I am awarded a scholarship, listing my name, major, hometown, transfer college (if applicable), and the name and amount of the scholarship.


Updated 9.5.2012