Goodwill Scholarship Fee Assistance Application

Applicant Information

Parent / Guardian / Applicant’s Full Name

Address

City/Town

State/Province

ZIP/Postal Code

Primary Phone

Secondary Phone

Place of Employment (if applicable)

Annual Income

Type of Income

Spouse Information (if applicable)

Spouse’s Full Name

Primary Phone

Secondary Phone

Place of Employment (if applicable)

Annual Income

Type of Income

Household Information

Number of family members in household

List all family members in household

Family Member / Applicant Name	Relationship	Date of Birth	Age	Operations
Family Member / Applicant Name	Relationship	Date of Birth	Age

Certification

I certify that all information provided is true and correct and all names listed are family members residing in the household.

Applicant Signature

Date