Name of Applicant:   Sex:

Mailing Address:

City/State/Zip Code:

Date of Birth: Home Phone:

Cellular Phone:   U.S. Citizen: Yes No

Place of Birth:   Age:

Social Security #:  Martial Status:

Number of Dependants:

Do you currently work?  Yes No    Where:

Father's Name: Mother's Name:

Father's Occupation: Mother's Occupation:

Are you currently affiliated with a Funeral Home? Yes No

And so, who:

Educational Background - to be considered for a 100 Black Women Scholarship you must meet certain requirements.  Those requirements include half of the required coursework in Mortuary Science toward your Associate or Bachelor Degree.

High School Attended:

City/State:    GPA:

College Attended:

City/State: GPA:

Have you taken: Chemistry   Pathology   Restorative Art   Embalming

Are you currently enrolled in Mortuary School?   Yes  Now

If so, what school: City/State:

Are you affiliated with any Organizations, Clubs, Community Group or Fraternal Societies? If so, please list:

School Record- You are required to enclose the following: Letter of current standing from your mortuary school, a certified copy of your transcript, a biographical sketch with a current photograph, and a 250 word essay on "Why You Have Chosen Funeral Service As A Career".

Expected Date of Graduation: Type of Degree:

Have you taken or registered for the National Board Exam: Yes   No

What State do you plan to work in after Graduation:

Source of Information, regarding the 100 Black Women Scholarship Program

Select one.    School Counselor    Journal/Newspaper    College

                 Local Funeral Director    Relative/Friend    YB News

                    Purple Directory    NFD & MA       Other

Reasons for Financial Assistance:

Have you worked at a Funeral Home? Yes No  How Long:

Firm Name:

Address: Phone:

Would you like to be matched with a Funeral Service Mentor and Why?

    Signature:   Date: