Social Security #/SCC ID#:
Last Name:
Maiden/Other:
First:
M.I.:
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E-mail address:

Apply for admissions now.

1. I have completed and submitted an SCC admissions application:
Yes No  Date Submitted:  

2. To help determine my eligibility for specific scholarships, I MUST indicate here whether I plan to pursue the following college programs or careers (Read the list first, then select one): Select the Program or Career Accounting Accounting Assistant Administrative Assistant Agriculture Art Automated Manufacturing Automotive Tech or Collision Repair Business/Management/Marketing Chem. Dependency Counselor Child Development(at CSC) Computers/Info Tech Conservation Construction Technology Cosmetology Criminal Justice Dental Hygiene(at CSC) Drafting Drama/Theatre Education - Elementary Education - Teaching/Admin.(indicate field below) Electrical Engineering Electronic Technology Elect. Tech Biomed Elect. Tech Hardware/Network EMT or Firefighter/Paramedic Finance Graphic Communications/Desktop Publishing Health Health Info. Tech. Human Resources Journalism Language Arts Education Legal Administrative Assistant Literature Math Medical Administrative Assistant Medical Assistant Medical Coding Medicine Mortuary Science(at CSC) Music Nursing Prep Nursing 1st Year Accepted Nursing 2nd Year Accepted Office Administrative Assistant Pre-Engineering Precision Machining Radiologic Technology(at CSC) Radiography(at CSC) Railroad Operations(at CSC) Respiratory Therapy Small Business Entreprenuer Surgical Tech Science Veterinary Medicine Welding Other Undecided-Arts and Sciences major transferring to a 4-year school
Other or Education- Teaching/Admin. Field:

 Alternate Program (Read the list first, then select one): Select the Program or Career Accounting Accounting Assistant Administrative Assistant Agriculture Art Automated Manufacturing Automotive Tech or Collision Repair Business/Management/Marketing Chem. Dependency Counselor Child Development(at CSC) Computers/Info Tech Conservation Construction Technology Cosmetology Criminal Justice Dental Hygiene(at CSC) Drafting Drama/Theatre Education - Elementary Education- Teaching/Admin.(indicate field below) Electrical Engineering Electronic Technology Elect. Tech Biomed Elect. Tech Hardware/Network EMT or Firefighter/Paramedic Finance Graphic Communications/Desktop Publishing Health Health Info. Tech. Human Resources Journalism Language Arts Education Legal Administrative Assistant Literature Math Medical Administrative Assistant Medical Assistant Medical Coding Medicine Mortuary Science(at CSC) Music Nursing Prep Nursing 1st Year Accepted Nursing 2nd Year Accepted Office Administrative Assistant Pre-Engineering Precision Machining Radiologic Technology(at CSC) Radiography(at CSC) Railroad Operations(at CSC) Respiratory Therapy Small Business Entreprenuer Surgical Tech Science Veterinary Medicine Welding Other Undecided-Arts and Sciences major transferring to a 4-year school

3. While at SCC, I intend to participate in the following SCC sport: Select the Sport Cheerleading Men's Baseball Men's Basketball Women's Softball Women's Volleyball Women's Basketball

4.  My GED Average Score (if applicable) is:
Testing Location:
Date/Year of GED graduation:

5. I am graduating from or have graduated from one of the following High Schools in (enter the year) : Select School Aquinas Burlington Cantril Cardinal Stritch Central Lee Danville Deep River Fort Madison GED Grad Harmony Holy Trinity Home Schooled Keokuk Marquette Mediapolis Morning Sun Mt. Pleasant New London Notre Dame Oakville WACO Wapello W. Burlington Winfield/Mt.Union Missouri school Illinois school Other School None
Other:

6. I understand that I must complete a FAFSA to be considered for scholarships that assist students with financial need. (Note: March 1 is the recommended deadline for mailing or filing FAFSA.)

Complete the application online at the FAFSA website.
SCC institutional code = 004603

I have completed and mailed my FAFSA Award letter to the Foundation Office, and indicated on the form that SCC is one of the schools of my choice
YES NO
I will bring a copy of the FAFSA report to the SCC Foundation Office (required.)

7.  Some Foundation scholarships have preferences for people who meet specific criteria. (check ALL that apply to you.) In the next semester, I:

	am a current SCC Foundation scholarship recipient seeking continuation funding and/or additional assistance
	am enrolling or enrolled at the West Burlington Campus
	am enrolling or enrolled at the Keokuk Campus
	am enrolling or enrolled at the Mt. Pleasant Center
	am enrolling or enrolled at the Fort Madison Center
	am enrolling or enrolled at another SCC contracted site(e.g., cosmetology school, etc.) (State Site: )
	will be a 1st year student at SCC (have completed 0-28 credit hours)
	will be a 2nd year student or greater at SCC (have completed 29+ credit hours)
	am a Male
	am a Female
	am a certified firefighter (paid and volunteer are eligible) or am seeking certification for firefighter and/or paramedic/EMT
	am an employee or a child of an employee of Catfish Bend (name of Catfish Bend employee: )
	am a child, ward, stepchild, or grandchild of an active, retired or deceased Case/New Holland(CNH) employee and enrolling full-time(name of relative who is current or former employee of Case/New Holland Corp(CNH)).: )
	am a family member of a Golden Eagle Distributing Company employee (name of employee: )
	am a child, stepchild or legal ward of a half-time or greater employee of Southeastern Community College and enrolling full-time(name of SCC employee: )
	am a former Iowa DOC inmate or immediate family member thereof (To be eligible for this $500 Iowa State Penitentiary Kiddie Korner Scholarship, please indicate your relationship with the inmate:) self father mother brother sister daughter son husband wife
	am a citizen of the U.S. [Jones/Stewart]
	am an international student (a non-U.S. citizen) [Tallarico]
	have held leadership roles in an organization, association or business (I will provide 2 reference letters regarding my leadership and/or good citizenship). Complete questions 10 and 11.
	have been or am involved in extracurricular activities (must complete question 9 below to demonstrate).
	am a minority, single mother with children in school (through college age) that I am supporting
	am a non-traditional age person; age 24 years or older [Arledge, Bresch]
	am a non-traditional age female; age 24 or older,with a 3.0 cumulative GPA [AAUW Keokuk]
	earned at least a 3.0 High School cumulative GPA and am an academic achiever (transcripts mailed as proof)[Stein]
	earned at least a 2.0 High School cumulative GPA (transcripts mailed as proof)[Stevens]
	struggle academically in school but I am motivated to learn (transcripts and reference letters mailed)
	am a current Missouri resident [McKee, SEIPC, MVC]
	am a Carl Sandburg College student (be aware that CSC students are eligible for Illinois and CSC scholarships, too; SCCF awards may be used for books only)
	will have a FULL-time job while attending school(Employer: ) [Yohe, Loghry]
	will have a PART-time job while attending school(Employer: ) [Yohe]
	am enrolled/enrolling in: 12+ credit hours (FT) 9-11 credit hours (3/4) 6-8 credit hours (HT) 1-5 credit hours (PT) during the semester beginning - Fall 2010 Spring 2011 Summer 2011
	am transferring to complete a BA or BS in Nursing after graduating from SCC [Bresch]
	am transferring to complete a BA or BS in Industrual Tech., Tech. Mgmt., Mfg. Eng. Tech., or Electrical Eng. after graduating from SCC [Bresch]
	am a dependent child of or a current customer of Alliant Energy
	currently work in a nursing home or a long term care facility or have in the last 6 months. [Dame]
	am a Phi Theta Kappa member.
	am enrolled in a Dual Credit Program earning high school and SCC credit at the same time.
	am a single mother. [Lawson, Loghry]
	am a Career Academy student in a local K-12 system
	am pursuing a career in literature and will provide a portfolio of works to demonstrate my talents [Holsteen, Paule]
	will submit (minimum) 2 letters of reference
	am pursuing a career in literature, may include the study and writing of poetry, drama, or prose I will submit a sample of written prose or poetry or a resume of credits in dramatic arts production by the stated application deadline. [Holsteen, Paule]
	will have completed high school Algebra I or higher and one lab science course before enrolling next term at SCC [NSF STEM]

8. My career goal is:
Here's how a Foundation scholarship will assist me in meeting my life's goals (provide a written statement):


9. High School/College curricular/extracurricular/community activities in which I have participated (provide a list)
(If N/A then please enter "none"):


10. The following describes my active participation in community service/leadership/citizenship activities (e.g., chairman or president, club member, volunteer, etc.) - (provide a list or written statement)
(If N/A then please enter "none"):


11. I understand that the Foundation has a preference for applications with at least two general reference letters (helps the committee decide.)
Note 1: Scholarships listed below have additional specifications for reference letters and/or supplemental materials. Please see SCC Foundation scholarship list for details.
Note 2: Reference letters are usually requested from current or former employers and teachers, counselors, neighbors, friends, and associates - but usually NOT from relatives.
Questions? View a reference letter template.

I wish to be considered for one or more of these scholarships, and I must be eligible to be considered - (see scholarship list for eligibility details) Thus I will comply with the following reference letter requirements:
Check all that apply.

	Ruth Gulden Holsteen and Charles Sophus Holsteen Memorial and Laurine Paule Scholarship (2 reference letters from teachers or professionals in Literature or a related field and a portfolio of works to demonstrate my talents)
	Helen Jones/ F.L. Stewart (2 reference letters regarding good citizenship)
	Nancy Neafie Memorial (2 reference letters from instructors, employers or business associates) to demonstrate my academic abilities
	Fine Arts (2 reference letters from persons qualified to judge talent in Fine Arts Music, Art, Graphic Arts, Drama/Theatre)
	Anthony Tallarico Memorial (2 reference letters demonstrating leadership or achievements)
	Burlington Kiwanis (2 reference letters demonstrating ability, interest and motivation to succeed in his/her chosen field)
	Higher Education Association (2 reference letters from SCC faculty and required essay)
	HEA Scholarship essay requirements can be found here.
	Kathi Mertens Chemical Dependency Memorial (2 reference letters from SCC faculty and required essay)
	Kathy Mertens Scholarship essay requirements can be found here.
	STEM Scholarship (2 reference letters, copy of high school transcripts showing you have completed Algebra I or higher and one lab science course)

12. READ THIS SECTION BEFORE SUBMITTING THE APPLICATION:

1. I declare that the information on this application form is true and accurate to the best of my knowledge.
2. Required/Mandatory Submission: I will submit my FAFSA financial aid award letter to the Foundation office by the Foundation Scholarship application deadline.
3. I understand that a Scholarship Committee or others will determine the scholarship(s) for which I am eligible based on the information included in and mailed for this application.
4. If I am awarded a scholarship, I hereby authorize the SCC Foundation to use my name in news releases or publications, and I will submit a thank you letter to the SCC Foundation Office to be shared with the donor and possibly for promotional purposes.
5. If I do not complete a full semester of study at SCC and receive a refund, I will reimburse the SCC Foundation a portion of the refund proportionate to my scholarship award.
6. If I do not maintain satisfactory progress, I may be ineligible to receive the next semester or next year award unless I submit an appeal letter and receive approval for the award to be reinstated.
7. I am eligible to apply for continuation or renewal scholarships only if I maintain the specified scholarship eligibility requirements.
8. [Required/Mandatory Submission] For graduating high school students, GED graduates without college experience or persons without any college experience: I will submit to the Foundation office an ORIGINAL High School transcript that includes at least 7 semesters of grades or my GED scores by the stated deadline.
9. [Required/Mandatory Submission] For non-graduating high school students with earned college credit: I will submit to the Foundation office an ORIGINAL College transcript from my last higher educational institution by the deadline.

Note: For applications submitted via the Internet, required supplemental materials (FAFSA, transcripts and reference letters) must be mailed and received by the Foundation Office by the stated scholarship application deadline.