Available to individuals who meet at least one of the following eligibility criteria; please check all that apply to you:

Incoming freshman ages 18-25, who have been raised through the child welfare system and have no form of financial support
College-age youth and adults with physical disabilities
Returning students who are 25 years or older who have dependents in their family unit

Applicants must also meet all of the following requirements:

Personal Data

First Name:
Middle Name:
Last Name:

Permanent Address

Street (Include Apartment Number):
City:
State:
Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Postal Code:
Country:
E-mail Address:
Home (or cell) Telephone (include area code): - -
Work Telephone (include area code): - -

Schools of my Choice: ASU MCCCD I plan to attend Full-time 3/4-time part-time

Qualifications

Are you a US Citizen? Yes No
Are you a legal resident of Arizona? Yes No
Are you a legal resident of Indiana? Yes No

Birth Date (month-day-year): - - Age:

Marital Status: Single Married Divorced Widowed

Are you physically disabled? yes no
If yes, please explain the nature of disability:

Do you require auxiliary aids or services related to your disability? yes no
If yes, please explain:

Have you ever been under the care of the child welfare system/ward of the court? (see eligibility definitions for clarification.) Yes No

If yes, in what state?
Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Do you have dependents? Yes No

List the age(s) of dependant(s):

Gross Annual Household Income: (A 1040 will be required for application to ASU)

Do you have any means of support other than that listed above? Yes No

If yes, please explain:

Did you file the FAFSA (Free Application for Federal Student Aid)? Yes No

Academic Information

Name of High School:
Street Address:
City:
State:
Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
Zip Code:

List any colleges or universities you you have previously attended and the number of credit hours completed

Other Relevant Data

List the school or community activities in which you have been most involved in order of importance to you.

How did you hear about the Nina Mason Pulliam Legacy Scholarship Program?

Essay Question: Please discuss, in 1-2 typed pages, based upon one or more of the eligibility criteria (as listed on the front of this application), how you qualify for the scholarship. What are your life goals and how will obtaining a college degree further these goals? How do you plan to balance your personal and academic responsibilities? What support systems do you currently have/need to help you succeed? (Please note: we encourage you to use a word processor and to cut and paste your essay below)