Name: _____________________________________________________________________

First Middle Last

Home Address: _____________________________________________________________________

Street

_____________________________________________________________________

City State Zip Code

Email Address: __________________________________ Phone # (___) _________________

Date of Birth: __________________________________

Applicant’s High School: __________________________________

Graduation Date or Expected Graduation Date: _________________

Name of College: ____________________________________________________________________

College Address: ____________________________________________________________________

Street

____________________________________________________________________

City State Zip Code

Name: _______________________________ _______________________________

Daytime Telephone: _______________________________ _______________________________

Occupation: _______________________________ _______________________________

Employer/Business: _______________________________ _______________________________

College Education, If Any: _______________________________ _______________________________

Degree/Year: _______________________________ _______________________________

Area of Academic Interest: __________________________________________________________________

Counselor’s Name: __________________________________________________________________

1. Please list in detail your extracurricular activities, work/internship experience, community involvement, awards,

honors and leadership positions using additional paper if necessary.

If .Yes, please explain in what way you are of Persian descent (as defined above). Please be specific. If .No, please describe your involvement in the Persian Community.

3. Are there any circumstances that you would like Mehr Humanitarian Society Inc., Inc. Scholarship Committee to know?

1. How do you believe receiving this scholarship will help you give back to the Persian community?

2. What has been the largest obstacle you have faced in your lifetime and how were you able to overcome it?

If I am an applicant living in the United States, I understand that before any award can be made I must first apply to and be accepted at a recognized institution of higher learning. If I am an applicant living in Iran, I understand that before any award can be made, I must first complete at least one semester as a full-time student at a recognized institution of higher learning. I realize that accepting Mehr Humanitarian Society Inc., Inc. Scholarship Award requires me to register for and complete at least the course load required to retain standing as a full-time student at the

institution that I am attending. The award will be made for one academic year. I understand that if I receive a grant, I must submit a current college transcript to Mehr Humanitarian Society Inc., Inc. Scholarship Committee at the end of the academic year along with a summary of extracurricular activities undertaken and any honors or recognition

received. The information provided on this application is correct and true to the best of my knowledge. I hereby authorize the release to Mehr Humanitarian Society Inc., Inc. Scholarship Committee of any information held or to be held by either secondary school, college, or university officials, or others, including but not limited to personal evaluations and transcripts. I understand that this material may be kept confidential both from me and the public, and I waive any right of access that I might have by law. I agree to permit my name, likeness, and non-financial information to be used in connection with any public disclosure of Mehr Humanitarian Society Inc., Inc. Scholarship Award.

_____________________________________ ________________

Signature Date

c/o P.O. Box 591 Allendale NJ 07401

ESTIMATED RESOURCES ESTIMATED EXPENSES

A. From Parents or Guardian $_______________ A. Tuition $_______________

From Relatives and Friends $_______________ B. Room and Board $_______________

From Savings or Assets $_______________ C. Student Fees $_______________

From Student Earnings $_______________ D. Books and Supplies $_______________

*B. From Other Schools. /Grants $_______________ E. Travel $_______________

C. From Other Loans $_______________ F. Other $_______________

D. From Other Sources $_______________

Mehr Humanitarian Society Inc., Inc.

Scholarship Committee,

c/o P.O. Box 34 Allendale NJ 07401

Include yourself, your parent(s), your brothers and sisters, and other relatives. Attach extra sheet if necessary.

Name of Year in Live at

School or School or Parent’s Full- School or

Name Age College Contribution Time College

______________________ ___ _____________ _____ __________ Y N Y N

_______________________ ___ _____________ _____ __________ Y N Y N

_______________________ ___ _____________ _____ __________ Y N Y N

_______________________ ___ _____________ _____ __________ Y N Y N

_______________________ ___ _____________ _____ __________ Y N Y N

_______________________ ___ _____________ _____ __________ Y N Y N

_______________________ ___ _____________ _____ __________ Y N Y N

(Students in the United States)

(Records below to be compiled by school official)

Candidates Name: ______________________________________________________________________________

First Middle Last

A. This candidate ranks(ed) ______ in a college prep group of ______ in an entire class of ______.

If precise rank is not available, please indicate rank to the nearest tenth from the top ______.

B. Standardized Test Scores

SAT - Verbal: ______ Math: ______ and/or ACT Composite: ______ and/or TOEFL (if applicable): ______

C. High School Grade Point Average: ______

Please also attach the applicant’s high school academic transcript to this form.

Name: ______________________________________________

Title: ______________________

School: _____________________________________________________________________________

Phone number: _____________________

_____________________________________ _______________

Signature Date

c/o

Candidate’s Name: ______________________________________________________________________________

First Middle Last

A. How long have you known this candidate? In which courses have you observed this candidate?

B. Please make a statement about this candidate’s academic ability, areas of particular strength, and, if an

Applicant has not completed at least one semester at a college or university, potential for success in college

study.

Describe school activities in which the student exhibits leadership.

Teacher’s Name: ______________________________________________

Title: ______________________

School: _____________________________________________________________________________

_____________________________________ _______________

Signature Date

c/o P.O. Box 591 Allendale NJ 07401