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Critical Needs Workforce Scholarship Application

Applications received after July 31, 2014 are for the 2015-2016 school year!
Last Name: * 
First Name: * 
Middle Name (N/A - if non-applicable):: * 
Preferred First Name:
Social Security Number: * 
Desired semester to enroll:
Street Address or Box Number:
City:
State:
Zip Code:
Home Phone: * 
Cell Phone: * 
E-mail: * 
Are you a South Dakota resident: *
 
High School/Vocational/Technical School/University you are currently attending:
____________________________________________________________________________________________________________
Date of high school graduation/GED (year):
Intended program of study:
Do you have the legal right to work in the United States: *
 
____________________________________________________________________________________________________________
Please provide us with three references from people other than close family members who know you well.
1. Name: * 
Title: * 
Company: * 
Relationship: * 
Phone: * 
E-mail: * 
Years Known: * 
2. Name: * 
Title: * 
Company: * 
Relationship: * 
Phone: * 
E-mail: * 
Years Known: * 
3. Name: * 
Title: * 
Comapny: * 
Relationship: * 
Phone: * 
E-mail: * 
Years Known: * 
____________________________________________________________________________________________________________
I certify that the information in this application is true and complete to the best of my knowledge. Furthermore, I understand that by agreeing to accept this scholarship, I agree to work in a training-related career in South Dakota after I complete my program. If I do not accept employment in a training-related field in the state, I am obligated to re-pay the funds. If I withdraw from school or change to an academic program for which my scholarship does not qualify, I am obligated to re-pay the funds. I further understand that if I withdraw from school or change to an academic program for which my scholarship does not qualify after the selection for a scholarship award, but before the award is paid, I am no longer eligible to receive the scholarship funds.
Signature (Type name; typing your name is the same as signing): * 
Date (--/--/--): *