Please type or print clearly.

Applicant's Name _______________________________________________________

Permanent Address_______________________________________________________

_____________________________________ Telephone_________________________

Current Address (if different from above)____________________________________

_____________________________________ Telephone_________________________

E-mail address:_________________________________________________________

Currently enrolled full-time:

College/University______________________________________________________

College/University City_________________________________________________

Year of Study in '14-15:____Freshman ____Sophomore ____Junior ____Senior

Graduate Student: Year___________ Professional Student: Year____________

List Institutions Previously Attended (High School and/or College):

________________________________________________________________________

________________________________________________________________________

Attach the following documents:

1. Applicant's Letter: Describe your career goals and how our scholarship might help you to achieve them. Give us a brief biographical sketch - tell us about your academic interests, your extracurricular activities, awards/honors you may have received and any community service you have been involved in. Also please describe your financial need.

2. Two Letters of Recommendation: From teachers, professors, employers or other professionals who know you well.

3. Official academic transcripts. Post secondary students should obtain transcripts from all colleges/universities attended. High school seniors should obtain them from current and any previous high school attended.

4. State Officer's Letter: A letter from a state officer of the National Federation of the Blind of Connecticut confirming that you have discussed your application with him or her. Call our state office for help on this.

Applicant’s Signature_______________________________Date________________