A. PERSONAL INFORMATION

 Name: ___________________________________________________ Date of Birth: _____________________________

 Address:__________________________________________________________________________________________

Telephone Number: Home (_____) _______________

 Work (_____) __________________________  E-mail (if available) ____________________________________________

 Sex:  □ Male:  □ Female   

 Citizenship:      □ U.S. Citizen                □ Permanent Resident                       □ Other________

 Ethnicity:                  __Asian                  __Native American          __Black                __Other
                                  __Pacific Islander    __Hispanic (non white)       __White

Name, address and phone number of nearest relative who would know your whereabouts: __________________________________________________________________________________________________
__________________________________________________________________________________________________

Parents'/Guardians' names, address, phone number __________________________________________________________
__________________________________________________________________________________________________

College or University attending___________________________________________________________________________

Enrollment status □ part-time □ full-time student

Other earned degree (s)_______________________________________ Institution_________________________________
Expected graduation date   _____________________________________

B. Essay 

 * Submit an essay consisting of between 400 and 500 words. In your essay, include answers to the following questions.

1.    What is your reason for entering the field of education? 

2.    What are the qualities that define a good educator?

3.    What is your role or how do you plan to contribute to the field of education?

C. SCHOLASTIC INFORMATION

Current Grade Point average (overall) _______

D. FIELDWORK AND INTERNSHIPS

D1.  List all current and/or past fieldwork and internship experiences.

D2.  RELATED ACTIVITIES, TALENTS, AND ACCOMPLISHMENTS

E. REFERENCES

Please list the names & addresses of the two persons who will provide you with letters of recommendation.

F. FINANCIAL AID

Attach any Financial Aid forms that may show evidence of economic need.

How did you first hear about this scholarship?
______________________________________________________________________________________

I certify to the correctness of the answers given above.  If assistance is granted me, I promise to answer
promptly all letters pertaining thereto, to keep Greater New England Alliance of Black School Educators (GNEABSE) informed of any change in my address.

I hereby give my permission for the GNEABSE Scholarship Committee members to share information
relevant to my application among themselves.

____________________________________________________       __________________

                                     Applicant's Signature                                                                   Date

 If any part of the application is incomplete, it will not be considered.

Applications must be typed or filled out legibly in INK.  Pencil is not acceptable. 
The complete application must be postmarked by February 6, 2009. Please mail to:

Greater New England Alliance of Black School Educators
Scholarship Committee

P.O. Box 2633
Hartford, CT 06146-2633

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