1. Name: ______________________________________________________________
2. Address: __________________________________________ Zip _______________
3. Social Security Number _____ - _________ - _____
4. Phone: (_____) ________________
5. Will you be enrolled in six (6) or more units Fall 2010? ___________
6. Cumulative Grade Point Average (GPA): _________ (Submit copy of transcripts)
7. What are your educational goals? __________________________________________
8. Father's Name: __________________________ Occupation: ____________________
9. Mother's Name:__________________________ Occupation: ___________________
10. Estimated Yearly Family Income: _________________________
11. Will you need to work while in college? ______________
12. Please list any past or current extracurricular activities. (Provide dates)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

13. Please list any awards and/or honors you have received.

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

14. Attach a Letter of Recommendation from someone other than a family member. It may be from a supervisor, teacher, employer, counselor, clergy, etc.
15. Please answer each question below. You can use additional space on back of this questionnaire.

1. What is the Chicano/Latino experience to you?

 

 

 

 

 

 

 

 

 

 

 

2. Please state in your own words how achieving your educational goals will benefit the Chicano/Latino community

Applicant's Signature: _______________________________ Date: __________________

*Recipients of previous CLEA scholarships ineligible to apply.