Student Name: ____________________________________________________________

Social Security Number: _____________________________________________________

Home Phone Number:  ______________________________________________________

E-mail Address: ___________________________________________________________

Home Mailing Address: _____________________________________________________

                                    ______________________________________________________

Number of Hours Completed at the College Level: _________________________________

Name of College Attended: ___________________________________________________

Address of College Attended: _________________________________________________

Phone Number of College Attended: ____________________________________________
 

Please answer the following questions by circling the appropriate answer. In order to qualify for the Scholars Program, you must be able to answer yes to all of the following questions.

1)      Do you have 12 or more hours of credit at the college level?

            Yes                   No

2)     Did you have a cumulative grade point average of 4.5 (on a five point scale)?

            Yes                   No

3)     Can you confidently expect to get two letters of recommendations from former teachers of yours, or from at least one teacher and one division head?

            Yes                  No
 

Please answer the following questions. You may use extra paper if necessary.

1)     Please list your accomplishments at school, if any. You may include high school academic and personal achievements. (Such as scholarly awards, prizes, clubs, organizations etc.)
 
 
 

[More on the back, please.]

2)     Please list the names of two of your college instructors who will serve as references:

        Name of Instructor: ____________________________________

        Place of Employment: ____________________________________

        Work Phone: __________________________________________

        Name of Instructor: ____________________________________

        Place of Employment: ____________________________________

        Work Phone: __________________________________________

3)     What are your plans for your education?

4)     What are your current interests or hobbies?
 

By signing this document, I, the candidate for the Scholars Program, am asserting that the information contained herein is factually true, to the best of my knowledge.
In addition, this signature constitutes my pledge to abide by the policies and requirements of the DACC Scholars Program and to make every effort to succesfully complete these requirements prior to graduation.  I further understand that failure to complete all the Scholars Program requirements will preclude me receiving any recognition for having participated in this program.

Student Signature: ________________________________________________ Date: ______________

Director of Scholars Programs: ______________________________________ Date: _______________

Date Application Received: _____________________
 
 
 
 
 

Please print this form, fill it out, and return it to the following address:

Lori Garrett, Director of Scholars Programs
Danville Area Community College
MMC
2000 East Main Street
Danville, IL 61832
 
 
 

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