Minority Scholarship Self-Declaration Form
Please complete this form to self-declare your minority status for scholarship eligibility review. All information will be used solely for scholarship assessment purposes.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Educational Institution Name
*
Course or Program of Study
*
Current Year or Level of Study
*
Please Select
High School
Undergraduate - First Year
Undergraduate - Second Year
Undergraduate - Third Year
Undergraduate - Fourth Year
Postgraduate
Other
Minority Group Self-Declaration
*
Please Select
Muslim
Christian
Sikh
Buddhist
Parsi
Jain
Other
Background Details Supporting Minority Status
*
I hereby declare that the information provided above is true and complete to the best of my knowledge.
*
I agree
Submit
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