KSHATRIYA MITRA MANDAL OF CALIFORNIA

SCHOLARSHIP APPLICATION FORM

Please follow the attached instructions very carefully to avoid disqualification. Write or describe any
required information on a separate sheet of paper, if space is not enough on the application.

TYPE OR PRINT CLEARLY IN BLACK INK.

1. PERSONAL INFORMATION

Name:_________________________________________________________________________________
Address: _______________________________________________________________________________
City:________________________________ State:__________________ Zip:_______________________
Home Phone Number: ________________________ Cell Phone Number: _________________________
Email Address:__________________________________________________________________________

2. EDUCATIONAL BACKGROUND

School, College or University:______________________________________________________________

Address: _______________________________________________________________________________
Anticipated Graduation Date:_____________________ GPA: ___________________________________
(You must submit official school transcripts with application.)

3. EMPLOYMENT HISTORY: ____________________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
____

4. SPECIAL ACHIEVEMENT/HONORS AND RECOGNITION________________________________

_______________________________________________________________________________________
_
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
____

5. EXTRACURRICULAR ACTIVITIES: ___________________________________________________

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
___

6. COLLEGE OR UNIVERSITY APPLIED FOR:

Name: _________________________________________________________________________________
Address:________________________________________________________________________________
City:________________________________ State:__________________
Zip:________________________
Signature:_______________________________________________Date:__________________________

APPLICATION DEADLINE: MAY 31, 2010

Note: There will be no exceptions. Application must be postmarked no later than MAY 31, 2010
FORM MAY BE PHOTOCOPIED