Register – LPF-Chicago

Name

First Last

Social Security Number

Current Mailing Address

Street Address Address Line 2 City State ZIP Code

Permanent Address, If different from above

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Date

Martial Status

Single
Married
Divorced
Widow

How many children do you have?

What are there ages?

Ethnic Origin (optional)

American
African American
Asian/Pacific Islander
Hispanic
White (non-hispanic)
Other

Are you a US citizen?

Yes
No

Are you a permanent resident?

Yes
No

Are you a Veteran?

Yes
No

Household Income last year?

When do you plan to begin class?

Jan Quarter
Feb Quarter
Apr Quarter
Jul Quarter
Aug Quarter
Oct Quarter

To which school are you applying?

What is your major area of academic interest? (select all that apply)

What type of credentials are you seeking?

Associate ( 2 years )
Diploma

List all High Schools, GED, Colleges, Universities and other schools you previously attended (Starting from the most recent)

School Name	City/State	Date Attended	Diploma	Graduation Date

Do you intend to apply for Financial Aid?

Yes
No

Are you currently employed?

Yes
No

If so where do you work?

Name of the Company	Position	location

Tell us about your past employers:

Name of the company	Period	Position	Salary	Reason for leaving

Please state in 250 words or less “Why do you want to get Training”?

Consent*

I Understand that I am applying for scholarship. If awarded I understand that it is for one quarter only but renewable each quarter if I receive a Grade point average of 2.0 or better. I further understand that to be eligible for the scholarship 1) I must pursue career-based education programs, 2) Be enrolled in full time status and 3) Will have to demonstrate Financial need.

Date

Signature