:: HATHAWAY SCHOLARSHIP APPLICATION FORM ::

Name: Phone: Mailing Address: City: State: <Select> Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 West Virginia Wisconsin Wyoming Guam Puerto Rico Armed Forces Americas (AA) Armed Forces Outside Americas (AE) Armed Forces Pacific (AP) New Brunswick Newfoundland Alberta Northwest Territories Nova Scotia Prince Edward Island Quebec Saskatchewan Ontario Yukon Territory Manitoba British Columbia None Zip: Physical Address: City: State: <Select> Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia 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 West Virginia Wisconsin Wyoming Guam Puerto Rico Armed Forces Americas (AA) Armed Forces Outside Americas (AE) Armed Forces Pacific (AP) New Brunswick Newfoundland Alberta Northwest Territories Nova Scotia Prince Edward Island Quebec Saskatchewan Ontario Yukon Territory Manitoba British Columbia None Zip: Email Address: Social Security # or CC Student ID #: I am requesting the Hathaway Scholarship be initiated for the following term and year: Fall       Spring       Summer     of 20 High school graduated/will graduate from: Date high school graduated/will graduate from: OR If GED, High school(s) attended: And GED completion date: OR Home school graduation date: I plan to attend college: Full Time (12+ credits per semester) Part Time (6-11 credits per semester) Are you planning to apply for the need-based portion of the Hathaway Scholarship Program? Yes (FAFSA required if yes) No Please answer all the following questions: Are you a US citizen? Yes        No Are you a male? Yes        No If a male, have you complied with the selective service requirements for registration? Yes        No Are you in default on a federal Title IV education loan? Yes        No Do you owe a refund on a federal Title IV student aid program? Yes        No Under penalty of false swearing, have you been convicted of a felony in this state or another jurisdiction? Yes        No Are you incarcerated? Yes        No By submitting this application I certify that all information provided is true and correct. I understand that I must apply for and be admitted to Casper College and that I must provide all transcripts and test scores necessary to establish my eligibility for this scholarship.

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