Jorge Gomez Book Grant Application

The Quad Cities Mexican American Organization is committed to aiding young students of Hispanic descent in obtaining higher education. In an effort to accomplish this goal, the organization has created the Jorge Gomez, Sr. Memorial Book Grant Program. Through this program, selected students will be awarded a grant to assist students with the cost of books needed for classes for the first semester of the 2006-2007 school year.

The following information pertains to the book grant:

Applicants must be of Hispanic descent or be an immediate relative of an organization member (i.e. spouse, son, daughter, grandchild, great grandchild);
Applicants must have a minimum cumulative grade point average of 2.5 out of 4.0 (or equivalent);
Applicants must he accepted and attend a two-year of four-year accredited college or university, or graduate school, or trade/technical school;
Completed application may be sent to:

Quad Cities Mexican American Organization

P.O. Box 2557

Davenport, IA 52809

DEADLINE: Completed applications are due on or before July 1^st, otherwise applications will not be considered. NO EXCEPTIONS WILL BE MADE.
Book grant recipients will be selected by August 1^st, and will be notified shortly thereafter of this award;
Book grant recipients will be reimbursed toward books purchased; Please note: amount of award will depend on funds available;
Book grant recipients must present receipts for the books purchased prior to being reimbursed. The receipts must be sent to the Quad Cities Mexican American Organization no later than October 31^st;
If you are selected as a book grant recipient, your receipt of the book grant award reimbursement will be contingent upon you or a family member agreeing to serve community service hours consisting of helping on four (4) bingo days for four (4) bingo hours per day at the Col Ballroom during the current calendar year. A commitment for these community service hours will be required before you receive the book grant money. You may arrange your community service hours by calling (563) 322-4431.
For further information call Eloise Cervantes at 355-5927, Rita Navarro at 322-5638, or Maurie Gomez at 324-6145.
Applications must be accompanied by most recent transcript with cumulative GPA and Student’s name.

This form should be completed by the applicant.

I. Personal Information

1. Name __________________________________________________________

Last First Middle

2. Home Address ___________________________________________

3. City ___________________________ State __________ Zip ______________

4. Telephone No. _________________ Date of Birth ______________________

5. Social Security Number ______________________________

6. Parents’ Names _________________________________________________

7. Parents’ Occupations _____________________________________________

8. Parents’ Address ________________________________________________

City __________________________ State ___________ Zip _____________

9. Have you been accepted and are you attending a two or four year college or university, or graduate school or trade/technical school?

Yes ________ No _________

10. Indicate what year of college or graduate school you will be in.

Year _________________

11. If you are a relative of an Organization member, please identify the Organization member and your relationship.

Name of Organization Member ____________________________

Relationship ___________________________________________

12. Please list two persons for character references:

Name _____________________________ Phone _______________________

Address ________________________________________________________

Name _____________________________ Phone _______________________

Address ________________________________________________________

II. Educational Experience

Name and address of any high school, college or university attended and graduation dates:

_____________________________________________________________________

III. State your current cumulative grade point average and identify the grading system used

(i.e. 2.0 on a 4.0 scale = C; or, 2.5 on a 5.0 scale = C) _______________________

You must attach your most recent high school, college or graduate school transcript (your last year’s) and other documentation showing grades, rank in class, and current cumulative grade point average. Your application will not receive consideration without including this information.

IV. Work Experience (an additional sheet may be added if needed.)

Name and address of Company, date, and type of work

1. _____________________________________________________________________

_______________________________________________________________________

2. _____________________________________________________________________

_______________________________________________________________________

3. _____________________________________________________________________

_______________________________________________________________________

V. List community, school and cultural activities in which you have participated. (an additional sheet my be added if needed.

a. ____________________________________________________________

b. ____________________________________________________________

c. ____________________________________________________________

VI. List other organizations to which you have applied for financial aid for the school year and amount of award.

a. ____________________________________________________________

b. ____________________________________________________________

c. ____________________________________________________________

VII. Give the name and address of the college, university or graduate school or trade/technical school to which you have been accepted and intend to intend or attending. Also, indicate what year of college, university or graduate school you will be in (1^st, 2^nd, 3^rd, 4^{th, etc.}).

______________________________________________________________

VIII. The funding for these book grants is generated primarily through events like bingo which depend on volunteers to make them run. Please state whether you or a family member would be willing to donate some of your time to work as a volunteer at a Quad Cities Mexican American Organization function, such as bingo, and when you would be available.

______________________________________________________________

IX. State why you feel you should receive this book grant. Please state any special financial needs. Use the space below or include on a separate sheet.

______________________________________________________________

________________________________ ____________________

Signature Date