Mosaic Scholarship Application

Applicant Data
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number

Area CodePhone Number
E-mail
Educational Data
High School
Graduation Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
GED
Date Received GED
College/University Enrolled In
Full Time (12+ Hrs) Part Time (3-9 Hrs)
Major
Minor
Other
List all community service activities you have been involved in
Essay

Please complete a 500 word essay sharing how you intend to use your degree to help your community.
I certify that the information on this application is true and correct to the best of my knowledge.
Certify
Mosaic Church does not discriminate on the basis of age, sex, national origin, race, and/or disability.
Should be Empty: