DR. JUDITH JOAN SMITHSON GRADUATE SCHOLARSHIP FUND APPLICATION

First Name:      

Middle Name:  

Last Name:       

Ulid:                   

Street Address: 

City:                

State:                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

Zip Code:         

Telephone:         

Email:              

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Area of Graduate Study:  

Year of Graduate Study:     1 2 3 4

Name of Graduate Advisor: 

Cumulative Grade Point Average : /4.0 Scale

Did you complete your undergraduate education at Illinois State University?  Yes No

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Are you a member of the Coalition of Citizens with Disabilities in Illinois?  Yes No

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Are you disabled as defined by the Americans with Disabilities Act of 1990?  Yes No

Question 1. What is your disability?

Question 2. Please describe how your disability has impacted your life.

Question 3. Please describe how the award of this scholarship assist you in pursuing your graduate degree, certification program, and /or job enhancement program.

Question 4. How will this scholarship assist you in realizing your personal, educational, and professional goals?.

Date: 9/8/2008

Documentation of disability is required to be submitted to Disability Concerns, 350 Fell Hall by September 12, 2008 for your application to be considered complete. If you have questions regarding this documentation requirement please call 438-5853.

I verify that the above information is correct to the best of my knowledge. By submitting this application I am granting the Scholarship Committee the authority to verify my status as a graduate student and my GPA.