Name(Required) First Middle Initial Last BSU Student ID Number or Social Security Number(Required) Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Home Phone Office Phone Beginning Term(Required)FallSpringSummer ISummer IICollege Major Expected College Graduation Year High School Name High School Graduation Date College Hours Completed (If any)Other Colleges Attended (if any)Are you applying as a West Virginia Resident? Yes No Are you applying as a Border County Resident? Yes No SCHOLARSHIP CRITERIA Dependents of full-time, permanent faculty, classified, and non-classified staff. Student must remain in Academic Good Standing for renewal. Employee First Name(Required) Employee Last Name(Required) Location of employment Relationship to Employee Signature(Required)The information provided on this application form is true and correct, to the best of my knowledge. I authorize Bluefield State University to access my student records. In addition, if awarded, I grant permission to BSU personnel to release information on my academic progress to donors TweetShareShare
