Hathaway Scholarship Program
Application for Community Colleges

contact the college you will attend for their application.

Name 		__________________________________________________________________

Address 	__________________________________________________________________

City 		______________________________ State_____________ ZIP______________

Phone		___________________Social Security # or Student ID#:____________________

E-mail		__________________________________________________________________

I am applying for the Hathaway Scholarship beginning in the following term and year:
	_____Fall	    ______Spring	  _____Summer     	Year 20_____
High school graduation date (MM/YY)   ____________________________
High school where you graduated 	      ____________________________ 	
OR
GED completion date (MM/DD/YY)      _____________________________

	Wyoming high school attended prior to completing GED ___________________________ 
OR
Home school graduation date (MM/YY) _____________________________

I plan to attend the following college:
⁭ Casper College       ⁭ Central Wyoming College        ⁭ Eastern Wyoming College     ⁭ Northwest College                  ⁭ Laramie County Community College       ⁭ Sheridan College     ⁭ Western Wyoming Community College

______ Full Time (12+ credits per semester)   ________ Part Time (6-11 credits per semester)

Are you planning to apply for the need-based portion of the Hathaway Scholarship Program? 
(Completion of the FAFSA is required) _____Yes   _____No

Please answer all the following questions:
____Yes     _____No     Are you a US citizen?
____Yes     _____No	   If a male, have you complied with the selective service requirements for registration?
____Yes     _____No	   Are you in default on a federal Title IV education loan?
____Yes     _____No	   Do you owe a refund on a federal Title IV student aid program?
____Yes     _____No	   Have you been convicted of a felony in this state or another jurisdiction?
____Yes     _____No	   Are you incarcerated?

I verify under penalty of false swearing under Wyoming Statute 6-5-303 that the above information is correct.

______________________________________			______________________________
Signature							Date

Return the completed application to the college of your choice at the address below: