Mintz Scholarship Application

Please complete the following application for scholarship consideration.
All fields required, if applicable. Additional information is required; view complete rules and requirements for details.

BIOGRAPHICAL INFORMATION

First Name: Last Name:
Gender: Date of Birth: ?
Email:
Cell:
Home Address:
City: State: Zip:
School Address (If Different):
City: State: Zip:
Preferred Mailing Address (choose one): Home Preferred
Work Preferred
 
Marital Status:
Dependents:
Number of Family members (including self):
Number of Family members in college (including self):
Have you ever been a New Jersey resident?
If so, when were you a resident?
 
City/State where you intend to practice:
Optometric School:
Anticipated date of graduation: ?
Current Cumulative GPA in optometry school (Undergrad GPA if 1st year):

OTHER COLLEGIATE INFORMATION

Name/Location of school:
Years in Attendance:
Degree Awarded:
 
Name/Location of school:
Years in Attendance:
Degree Awarded:
 
Optometric Organizations & Offices:
Community Organizations & Interests:
Please list any on or off campus employment you have held during optometry school:
Special Optometric Interests:

FINANCIAL INFORMATION

Student's Expenses

 Last Academic YearAnticipated this Academic Year
Tuition and Fees
Books/Supplies/Equipment
Living Expenses (including rent/mortgage)
Transportation
Health-related Expenses
Miscellaneous
TOTAL

Student's Income

 Last Academic YearAnticipated this Academic Year
Aid from student's parents
Student's wages after taxes
Spouse's wages after taxes
Other income
Grants/Scholarships
Loans
TOTAL

STUDENT'S ASSETS AND INDEBTEDNESS

All Bank Account Balances:
Other Investments/Assets:
Total Student Loan Indebtedness: (include undergraduate and current year loans)
Other Indebtedness (please explain):$
During the last two years, did the parents claim the student as a dependent?
Will the student be a dependent this year?
 
Mother's Name:
Address:
City: State Zip
 
Father's Name:
Address (if different from Mother):
City: State Zip
   - denotes required fields