Kansas Promise Scholarship Application HiddenSTUDENT APPLICATIONAn application must be submitted to the Student Financial Aid Office of the student's educational institution for consideration for this scholarship. Students must also complete the Free Application for Federal Student Aid (FAFSA) Form.A. CONTACT INFORMATIONName(Required) First Middle Last Are there any previous names (married, maiden or alias) that you have used?(Required) Yes No If so, please provide.(Required)Social Security Number(Required) Date of Birth(Required) MM slash DD slash YYYY Current Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Permanent Address (if different from above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email Address(Required) Cell Phone Number(Required)Home Phone NumberB. RESIDENCY INFORMATIONHave you lived continuously in Kansas since birth?(Required) Yes No If no, indicate the month and year you began living continuously in Kansas.(Required) MM slash DD slash YYYY Are you a dependent child of a military service member who is permanently stationed in another state?(Required) Yes No C. EDUCATIONName of High School(Required) High School City, State(Required) High School Graduation Date OR High School Equivalency Exam (GED) - Date Passed(Required) MM slash DD slash YYYY Name the Kansas postsecondary educational institution you will attend.(Required)North Central Kansas Technical CollegeWhat program of student will you pursue?(Required)Please choose oneAssociate Degree in NursingAutomotive TechnologyAutomotive Collision TechnologyCarpentry/CabinetmakingCNA/CMADiesel TechnologyElectrical TechnologyHeavy Equipment OperationsInformation TechnologyPharmacy TechnicianPlumbing, Heating and Air ConditioningTelecommunications and Network TechnologyWeldingPractical NursingPromise scholarship recipients who change programs of student may have to repay the scholarship. Read the certification below before applying.Do you plan to enroll(Required) Part-time (6-11 hours) Full-time (12+ hours) Anticipated date of program completion(Required) MM slash DD slash YYYY Use first day oay of the month with the month and year you plan to graduate. *Students must complete their program within 30 months of receiving the Promise Scholarship.SCHOLARSHIP CERTIFICATION STATEMENT(Required) I certify that the information provided herein is complete and correct to the best of my knowledge, and that I have read and understand the description of the Kansas Promise Service Scholarship for which I am applying. I also certify that I understand the information that I have provided on this form is true. If asked by an authorized official, I agree to provide proof of the information that I have given on this form. I also understand that if I receive a Promise Service Scholarship that I will be obligated to sign a Service Agreement, as required by the Kansas Promise Scholarship Act. Furthermore, I understand that there is a service obligation for accepting a Kansas Promise Service Scholarship and if I default on the obligation in any of the manners identified in the Kansas Promise Scholarship Agreement, the amount of the scholarship I received MUST BE REPAID with the interest that as accrued from the date of origination of the award.Signature(Required) First Last Today's Date(Required) MM slash DD slash YYYY Δ
