COMPUTER SCIENCE SCHOLARSHIP APPLICATION FORM

Scholarship for which you are applying (may be more than one):

¨ Karlson (women only)

¨ Alumni

¨ Lubrizol

Name: ________________________________________ ID#: _________________________

Home Address:______________________________City/State/ZIP_______________________

Local Address: ______________________________City/State/ZIP_______________________

Major: ______________________________________________________________________

GPA: _______________________ Expected Graduation Date: ___________________________

Field Experience: _______________________________________________________________

_____________________________________________________________________________

Participation in H. S. Science Fairs as an Entrant or Judge: ________________________________

______________________________________________________________________________

Participation in Student Chapter of ACM: ______________________________________________

______________________________________________________________________________

Other Extra-curricular Activities: ____________________________________________________

______________________________________________________________________________

Career Objectives: _______________________________________________________________

______________________________________________________________________________

Financial Need: _________________________________________________________________

______________________________________________________________________________

Local Phone Number: __________________ Home Phone Number: _______________________

e-mail address: _________________________________________________________________

Signature: _________________________________________ Date: _______________________

Note: Attach statement explaining why you believe you qualify for the scholarship(s) to this form

Send completed form to Dr. W. Pelz, Dept. of Computer Science, by March 28, 2008.