Name______________________________________________________ DOB___________________
Address____________________________ City__________________ Zip_________
Home Phone (___)-_____-______
Cell Phone (___)-_____-______
Social Security # yes no US Citizen yes no
E-mail__________________________________
Driver's License yes no
If have car… Auto Make/Model_________________ Year________
Payments______________
How well does you car run? ________________________________________________
Highest Level of Education _________________________________________________
Date of High School Graduation or GED___________________________________
Have you applied for Federal Financial Aid? Yes No
Have you taken the ACT or COMPASS Assessment? Yes No
Total Monthly Gross Income ______________________
List sources all of monthly income______________________________________
_______________________________________________________________________________
List all credit card debt _________________________________________________
Date of Emancipation ___________________________________________________
Last Social Workers Name ______________________________________________
And Phone Number (____)-_____-_______
College of Choice________________________________________
Major/Program of Choice__________________________________
Do you have a drug history?________________________________
Have you ever been charged with a criminal offense? If so explain. This does
not automatically exclude you from this program, but we need to know about
each participants background.
__________________________________________________________________________________________
__________________________________________________________________________________________
Have you ever been involved in a criminal offense hearing? If so explain. This
does not automatically exclude you from this program, but we need to know
about each participants background.
__________________________________________________________________________________________
__________________________________________________________________________________________

*Please attach a brief autobiography which includes: your family upbringing
and background, your current living arrangements, your current status in
school and/or your job, your career goals and educational plans, and why you
want to be a part of this program.

**Also needed are three brief letters of reference from teachers, counselors,
social workers, employers, pastors, advisors, or one can be from a foster
parent.

***The application for the 2011-2012 year is due Tuesday, May 3, 2011.
Received applications are reviewed for an interview selection.

I certify that all of the above information and the attached autobiography are
true and accurate to the best of my knowledge, and I give permission for
Brighter Tomorrows Better Future to verify the above stated information
including and not limited to a credit report.

_______________________________
Signature
______________
Date

****Please mail or return your application, brief autobiography, and three
letters of reference to: