How long have you lived at this address?

How is permanent residence established?

Address of person living with

Place of registration to vote

Family's primary residence

Email Address *

Date of Birth

I am a

U.S. citizen

U.S. national

Resident alien

If you checked Resident Alien, fill out your VISA#

Are You a Veteran?

Yes

No

Which Branch?

Educational History:

High School Diploma

GED

Some Post High School

College Graduate and above

Vocational or Technical Training

Less than High School (last

List awards, scholarships, publications or special recognitions you have received. List in descending order of significance.:

Explain why you should be considered for a scholarship to Excel:

What additional personal information do you wish to share with the Excel scholarship committee?

Driver License Information:

Do you have a valid driver license?

Yes

No

If yes, what is the driver license number?

State

Have you ever been charged with a traffic violation?

Yes

No

If yes, list any traffic violations and points you have on your driving record