APPLICATION FOR SCHOLARSHIP ASSISTANCE

• Document Type: CREST
• Collection: General CIA Records
• Document Number (FOIA) /ESDN (CREST): CIA-RDP79-00639A000100100006-6
• Release Decision: RIFPUB
• Original Classification: K
• Document Page Count: 3
• Document Creation Date: November 17, 2016
• Document Release Date: June 16, 2000
• Sequence Number: 6
• Content Type: FORM

-Approved For Relea 2000/08/04: CIA-RDP79-00639 000100100006-6
APPLICATION FOR SCHOLARSHIP ASSISTANCE
3 . Official College Entrance n oerd results-- A titude Test--or equivalent America
ort essay (no more than 300 words) by the student about himself and his nlena
All information submitted will be kept in strict confidence by the Board of Trustees.
PARENT
1
NAME
2.
DATE OF BIRTH
3.
ADDRESS
- "
4.
IF NO LONGER EMPLOYED. DATE OF RESIGNATION
5A. IF DECEASED, DATE
OF DEATH
5e.
NAME AND ADDRESS OF SURVIVING PARENT OR GUARDIAN
STUDENT APPLICANT
6.
NAME
7.
DATE OF BIRTH
8.
PRESENT ADDRESS
9.
TELEPHONE NUMBER
10.
ACADEMIC BACKGROUND AND QUALIFICATIONS
NAME AND ADDRESS OF SCHOOL
(Indicate preparatory, high school, or college)
DATES OF
ATTENDANCE
SCHOLASTIC AVER-ATE-
AND CLASS STANDiNG
(Show size of char' )
11.
LIST ANY HONORS, AWARDS, PRIZES OR ACADEMIC SCHOLARSHIPS (?nd their amounts)
YOU HAVE
RECEIVED
12.
LIST RESULTS OF COLLEGE ENTRANCE EXAMINATION BOARD (Scholastic Aptitude Test)
Approved For Release 2000/08/04: CIA-RDP79-00639A0
OR AMERICAN COLLEGE TEST
00100100006-6
 13. ED C T I H LIED 0 T D TO AP L in order o pre crence
NAME OF
INSTITUTION
LOCATION
ACCEPTED
YES
NO
YES
NO
YE5
NO
YES
NO
YES
NO
14.
LIST WHAT
YOU HAVE BEEN ABLE
TO DO TO HELP MEET THE
EXPENSES OF YOUR EDUCATION
15.
LIST YOUR
EXTRACURRICULAR INTERESTS AND HOBBIES AND
EXPLAIN THE EXTENT OF
YOUR PARTICIPATION
16.
ATTACH A
RECENT PHOTOGRAPH OF
YOURSELF BELOW AND INDICATE THE DATE OF THE
PHOTOGRAPH
17.
r
DATE
18. SIGNATURE OF
APPLICANT
SP
19. DATE
20.
SIGNATURE OF PARENT
OR GUARDIAN
 [] f PAQS' MEIDor Rel asVPV8/04 : CIA-RDP7 039 QX0000 :'SECRET
ROUTING AND RECORD SHEET
SUBJECT: (Optional)
FROM:
DDP/Publications
G-G-01+ HQ
EXTENSION
NO.
DATE --- - -
11 January 1967
TO:
build
(Officer designation, room number, and
ing)
DATE
OFFICER'S
COMMENTS (Number each comment to show from whom
RECEIVED
FORWARDED
INITIALS
to whom. Draw a line across column after each comment.)
SSA/DDS
7-D-16 HQ
3.
4.
5.
6.
7.
10.
12.
13.
14.
15.
FORM
3-f.2
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