Alumni Association of The City College of New York

Title of Scholarship to which you are applying:
1. Last Name:	First Name:
2. Address:	City:		State:	Zip Code:
3. Telephone:	4. Date of Birth: Month: DAY YEAR

5. Major:	6. GPA:	7. Expected Graduation Date: Month: Day Year
8. Place of Birth:		9. Sex: Male: Female:
10. ETHNICITY/RACE (requirement for Harburg Scholarship only):		11. With whom do you live with? (check all that apply) Parents/Guardians Alone Roommates
12. Attach a one page statement giving additional information you tell would help the Committee evaluate your application. Please include your goals, community and/or College service, extra- curricular activities, family circumstances and extent of self-help.	13. Please list name, title and relationship of 2 references and attach their recommendations (one must be from a faculty or staff member of the College).		14. Be sure to check requirements for the individual scholarships so that you include any additional items or information needed with your application.

**Please note that students receiving a Scholarship or Cash Award from the Alumni Association of CCNY are expected to attend (as our guest) at the Annual Alumni Dinner held at the Roosevelt Hotel, on November 2005, where the Scholarships or Cash Awards will be presented.**