The O Brien-Vrba Scholarship Trust Scholarship Application Form 2017-2018 Academic Year Applicants are limited to FULL-TIME Graduate Students with a 3.0 GPA minimum GRADUATE STUDENT APPLICATION Please refer to the last page for a list of required documentation needed to process this scholarship application. ALL DOCUMENTATION MUST BE POSTMARKED BY APRIL 15, 2017. Information provided will be held in confidence and will not be shared with any third party. GENERAL INFORMATION Name: First Middle Last Home Number: Cell Number: Email: Date of Birth: Single: Married: SCHOLARSHIP QUESTIONS 1. Religious Faith: (i.e. Catholic, Protestant, Jewish, Muslim, etc.) 2. High School Attended: 3. Undergraduate School Attended: Cumulative GPA: Scale: Minimum of 3.0 on a 4.0 scale (or the equivalent) Note: Applicant must provide an OFFICIAL transcripts from all colleges and or universities that the applicant has attended or is currently attending. 1
4. I am a senior in college and have been accepted into a graduate program NOTE: Copy of Acceptance Letter is required I am currently a graduate student 5. Graduate School you are planning to attend in the 2017-2018 Academic Year: Degree Expected: 6. Estimated Tuition for 2017-2018 Academic Year: 7. Estimated Financial Aid for 2017-2018 Academic Year: Grants: Scholarships: 8. Current Educational Debt: 9. Financial Information: If applicant is claimed as a dependent by parents, the following questions must be answered and the following documents must are required a. Parents adjusted gross income from 2016 Federal tax return: A copy of pages 1 and 2 of parents joint or each parent s individual 2016 Federal Income Tax return showing b. Applicant s adjusted gross income from 2016 Federal tax return: A copy of pages 1 and 2 of the applicant s 2016 Federal Income Tax return showing c. Number of family members attending college in 2017-2018: If applicant s filing status is Single and applicant is NOT claimed as a dependent by parents, the following questions must be answered and the following documents are required a. Parents adjusted gross income from 2016 Federal tax return: b. Applicant s adjusted gross income from 2016 Federal tax return: A copy of pages 1 and 2 of the applicant s 2016 Federal Income Tax return showing 2
Financial Information, Continued: If applicant s filing status is Married filing jointly, Married filing separately, or Head of household, the following questions must be answered and the following documents are required a. Applicant s adjusted gross income from 2016 Federal tax return: A copy of pages 1 and 2 of applicant s (or joint) 2016 Federal Income Tax return showing b. Spouse s adjusted gross income from 2016 Federal tax return: A copy of pages 1 and 2 of spouse s (or joint) 2016 Federal Income Tax return showing c. Number of family members attending college in 2017-2018: Additional financial hardships that you would like to disclose 10. Community Service Activities (please list below) Indicate any leadership positions i.e.: Organization President, VP, Secretary, Treasurer etc. NOTE: At least one letter from a person responsible for coordinating community service attesting to your involvement is required. Additional weight is given for leadership roles. If the community activity included a leadership role, please have the supervisor of the activity so indicate. Community Service activities do not include school clubs unless specific community service was performed. Reference letters must be on letterhead and include the signature and title of the reference. 3
11. Provide any other information for Advisory Committee consideration (optional): 4
Have you included the following required documents with your application? o One page typed letter stating why you should receive the scholarship. o OFFICIAL transcript from all colleges which you have attended and/or are currently attending. o Copy of your letter of acceptance to the school you will be attending. o See Question #9 above and submit ALL applicable 2016 Federal Income Tax returns. PLEASE BLACK OUT SOCIAL SECURITY NUMBERS. Note that applications with total adjusted gross income (from all applicable parties) exceeding $100,000 will not be considered. o A letter from a teacher, advisor, or member of the clergy attesting to your performance and character. Letter must be on letterhead and include the signature and title of the reference. o At least one letter, from a person responsible for coordinating community service, attesting to your involvement is required. Additional weight is given for leadership roles. If the community activity included a leadership role, have the reference indicate so in the letter. Community service activities do not include school clubs unless specific community service was performed. Letter must be on letterhead and include the signature and title of the reference. Please do not bind or put in folder. ************************************************************************************************* CERTIFICATION I do hereby certify that the above information contained herein is, to the best of my knowledge, true and accurate. I am fully aware that any intentional falsification of the information contained herein may result in the denial of this application. Intentional misrepresentation, falsification, or fraudulent statements will result in reimbursement by me to the O Brien Vrba Scholarship Trust of any award paid on my behalf. Signature of Applicant Date Please answer all questions and sign/date your application. Incomplete applications will be disqualified. TRANSCRIPTS MAY BE MAILED SEPARATELY; SUBMIT ALL OTHER DOCUMENTS TOGETHER. ALL DOCUMENTS MUST BE POSTMARKED BY APRIL 15, 2017. Please mail your APPLICATION and REQUIRED DOCUMENTS to: Attn: Alexis Lundeen (O Brien Vrba Scholarship) PNC Institutional Asset Management 1900 E. 9th Street, 13th Floor (Mail Stop: B7-YB13-13-2) Cleveland, OH 44114 You will be notified of the status of your application once recipients have been selected. Notifications are sent in the months of July/August. Direct inquiries to alexis.lundeen@pnc.com or 216-222-2799 5