Hathaway

A P P L I C A T I O N

Student Information

Name
Student ID
Social Security Number
Date of Birth (mm/dd/yyyy)
Address
City
State
ZIP/Postal Code

What term and year would you like to begin using your Hathaway Scholarship?

		Fall	Spring	Summer	Year
		Fall	Spring	Summer	Year

If you have used your Hathaway Scholarship previously, please list what school(s) and what year.

		College	Dates Attended
		College	Dates Attended
		College	Dates Attended

What high school did you graduate from?

	Choose one	High School Name	Graduation Date
High School	High School Choose one	High School High School Name	High School Graduation Date
GED	GED Choose one	GED High School Name	GED Graduation Date
Home School	Home School Choose one	Home School High School Name	Home School Graduation Date

I am applying to attend LCCC:

	Full Time (12+ credits per semester)
	Part Time (6-11 credits per semester)

Are you planning to apply for the need-based portion of the Hathaway Scholarship Program?
(FAFSA required)

	Yes
	No

Please answer all of the following questions:

	Yes	No
Are you a U.S. citizen or a permanent resident alien?	Are you a U.S. citizen or a permanent resident alien? Yes	Are you a U.S. citizen or a permanent resident alien? No
If you are male, have you complied with the Selective Service registration requirements?	If you are male, have you complied with the Selective Service registration requirements? Yes	If you are male, have you complied with the Selective Service registration requirements? No
Are you in default on a federal Title IV education loan?	Are you in default on a federal Title IV education loan? Yes	Are you in default on a federal Title IV education loan? No
Do you owe a refund on a federal Title IV student aid loan?	Do you owe a refund on a federal Title IV student aid loan? Yes	Do you owe a refund on a federal Title IV student aid loan? No
Have you been convicted of a felony in this state or another jurisdiction?	Have you been convicted of a felony in this state or another jurisdiction? Yes	Have you been convicted of a felony in this state or another jurisdiction? No
Are you currently incarcerated?	Are you currently incarcerated? Yes	Are you currently incarcerated? No

Applicant Signature

By checking this box and submitting this application, I hereby certify that this application contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that should an investigation at any time disclose any misrepresentation or falsification, my application may be rejected or I may be dismissed from Laramie County Community College.

Date

mm/dd/yyyy