Permanent Address:	City	State	Zip

Current Address if Different from above	City	State	Zip

E-mail Address:	Permanent Telephone: (including area code)	Current Telephone: (including area code)

Name and address of nearest relative:
Name:	Relationship:

Street Address	City	State	Zip

Are you a U.S. Citizen? Yes No

Proposed Field of Study:	If Other explain:

Degree you will work to obtain:	If Other explain:

Name and Location of College or University to which you have applied:

Have you been accepted into this graduate program? Yes No

Date your studies began/will begin: Month Year

Will you be able to earn your degree within this scholarship year ? Yes No If NO, please explain:

Estimated Expenses per term - June 1 through May 31
(Enter values in whole dollar amounts)

	SUMMER	FALL	WINTER	SPRING
Tuition/fees
Books(estimate)
Room/Board
Other
TOTALS	$	$	$	$
GRAND TOTAL	$
Hours to be taken

Is this request for Semester or Quarter terms ?

APPLICANT'S COMMENTS: In 350 words or less provide reasons for choosing this profession,
motivation to pursue this degree, commitment to work with children and future goals.

CERTIFICATION (MUST BE SIGNED AND DATED)

I certify that the information given in this application is complete and accurate to the best of my knowledge. If I accept the NAJA Scholarship, I agree to fulfill the following obligations:

TO MAINTAIN A HIGH LEVEL OF SCHOLARSHIP AND BEHAVIOR AND TO SEND TO THE SCHOLARSHIP COMMITTEE A TRANSCRIPT OF ALL GRADES RECEIVED DURING THE SCHOLARSHIP PERIOD.

TO NOTIFY THE SCHOLARSHIP COMMITTEE OF ANY CHANGE OF NAME OR ADDRESS OR OF A CHANGE IN MY MAJOR FIELD OF STUDY OR SCHOOL.

Signature ___________________________ Date _____/___/_____

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APPLICANT'S COMMENTS: In 350 words or less, provide reasons for choosing this profession, motivation of this degree, COMMITMENT TO WORK WITH CHILDREN and future goals.

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