Office of Student Financial Aid 

                          2002 Rollins Hall 

1 Old Dominion University 

Norfolk, VA 23529‐0052 ● Telephone: (757) 683‐3683 ● Fax: (757) 683‐5920 

 

2018-2019 SCHOLARSHIP FORM FOR CONTINUING & GRADUATE STUDENTS

This form applies to the 2018-2019 academic year (Fall 2018 and Spring 2019) for students who have attended or are currently attending Old Dominion University. This form is used to select recipients for Annual and Endowed Scholarships offered by Old Dominion University. It is only necessary to complete this form if you meet any of the criteria listed below. The completed form must be received by Old Dominion University, 2002 Rollins Hall, Norfolk, VA 23529-0052, by

January 1, 2018.

I. GENERAL INFORMATION (Please Print)

Name (Last, First, Middle):__________________________________ University Identification Number: __________________

Current Address:

Permanent Address: ______________________________________________________

Current Phone Number: (____)_______________ Permanent Phone Number: (____)_______________

E-mail Address: ________________________

Month and Year expected to complete degree: ____________________________________________

II. CRITERIA (Please Check All That Apply)

□ Prior Resident of Hope Haven Home (FAHH)

□ Member of the military or a relative of a military member. (MAAD)

□ Dependent of active duty military personnel (MADP)

□ Honorably discharged from U.S. Armed Forces (FAAS)

□ Participate in extra-curricular activities, such as civic, sports, drama or student government activities (FAAC)

□ Have held a leadership position in any clubs or organizations (FALD)

□ Work on a high school, community or university publication (FAPB)

□ Member of Delta Sigma Lambda Sorority (FADS)

□ Member Pi Sigma Epsilon (FAPS)

□ Participant in university athletic program (intramural, club or intercollegiate) (FAAT)

□ Member of Kappa Delta Rho (FAKD)

□ Member of clubs and societies in the College of Engineering and Technology (FACE)

□ Graduate of Old Dominion University’s Lamberts Point Summer Program (FALP)

□ Member of high school CHROME club (FACH)

□ Son or daughter of Old Dominion University alumnus/alumna (LGCY)

□ Dependent of Old Dominion University faculty or staff, undergraduate was/will be claimed on parents’ taxes (FADO)

□ Child of VSPE member (FAVS)

□ Parent or grandparent is affiliated with Freemason Street Baptist Church (FAFS)

□ Physically disabled (FAPD)

□ Blind (FABL)

□ Have completed a considerable amount of non-paid volunteer hours (FNPV)

□ Resides or has resided in a Norfolk Redevelopment & Housing Authority property (NRHA)

□ Student, mother, grandmother or aunt is a member of Beta Sigma Phi (MBSP)

□ Graduate of the “Achievable Dream Program” in Newport News, VA (ACDR)

III. CERTIFICATION

I certify that the information I have provided on this application is true and complete to the best of my knowledge. I understand that information about me known to the Admissions and/or the Registrar’s Offices may be used to evaluate my eligibility for a scholarship and I authorize those offices to release information to appropriate scholarship committees. I further authorize release of my application to third parties for the purpose of scholarship consideration. If selected for a scholarship, I authorize release of biographical information for use in publicity related to the scholarship program. I further agree that I will notify the Office of Student Financial Aid of any changes (major, residence, etc.) which may affect my eligibility for a restricted award.

______________________________________________ ____________________________________

Student Signature Date

THIS APPLICATION CANNOT BE PROCESSED WITHOUT YOUR SIGNATURE

Other scholarships may be awarded to students who did not complete this form, where the above-named criteria are not a factor.

 Old Dominion University is an equal opportunity, affirmative action institution.  Minorities, women, veterans and individuals with disabilities are strongly encouraged to apply.