K. Wells Scholarship Application

University of Wisconsin–Madison Division of Continuing Studies

Karen Y. Wells Scholarship Application 2005-2006

Application deadline: April 15, 2005

Please read scholarship information prior to completing the application. Please print or type.

Attach the following to the completed application:

Submit the following materials and indicate their status. If these materials are not submitted by April 15, 2005 the application will be considered incomplete and will not be reviewed.

A 2-3 page essay (see Information for criteria.)
One letter of support from a professor, teaching assistant, advisor or official representative from a community group with which you are affiliated. Your reference's working title or position needs to be included in the letter.
Copy of your complete transcript to date
Signed copy of your 2004 Federal Income Tax Return
Not required to file Federal Income Tax Return because (please explain):

Application Form

Personal Information
1. Full Name
2. Date of Birth
3a. City/State/Zip
4. Phone number (including area code)
4a. E-mail Address
5. Circle one: Male Female
5a. Circle one: Undergraduate Graduate Professional
6. Head of household? Circle one: Yes No
6a. Do you provide primary economic support for this household?
6b. How many hours per week do you work, if any?
6c. Age(s) of child/children living with you:
6d. Are children declared as dependent(s) on tax returns? Circle one: Yes No
6e. Number of semesters you have been enrolled in school while child/children lived with you?

Educational Experience
7. Have you completed an undergraduate degree? Circle one: Yes No
7a. Circle one: Enrolled at an accredited institution Admitted to an accredited institution
7b. How many credits are you taking this semester? at (name of institution):
7c. Number of college credits completed:
7d. Number of college credits completed elsewhere: at (name of institution):
7e. Total college credits completed (excluding current semester) toward: Bachelor's degree ( ) Graduate/prof. degree ( )
7f. Cumulative undergraduate GPA:
7g. Cumulative graduate/prof. GPA:
7h. Anticipated credit load: Fall semester 04 ( ) Spring semester 05 ( )
8. For undergraduates: Anticipated major:
8a. For undergraduates: Anticipated graduation date:
8b. For graduate/prof: Anticipated degree/program of study:
8c. For graduate/prof: Anticipated graduation date:

Income (do not list any financial aid)

9a. Sources of Taxable Income in 2004
a. Employment	$
b. Interest/Dividend Income	$
c. Unemployment Compensation	$
d. Other Taxable Income	$
Describe:

9b. Sources of Untaxed Income in 2004
e. Social Security Benefits	$
f. DHSS Financial Assistance	$
g. Child Support	$
h. Veteran's Benefits	$
i. Worker's Compensation	$
j. Other Untaxed Income	$
Total Income for 2004:	$
9c. Do you anticipate any significant change in income in the next 12 months? (please explain)

10. How did you hear about this scholarship?

This statement must be signed or form will be returned.

I certify that all the information I have provided on this application is true, correct, and complete and that I am not delinquent in the payment of court-ordered child support and/or maintenance. If granted assistance, I will use it only for educationally-related costs while enrolled at accredited educational institution. I further authorize The Wendell Bryant Foundation, or its representatives, to obtain such additional information concerning my educational program and financial record as the above-named office may need to complete the processing of this application. It is also my understanding that the office may, as it deems appropriate, release to others who may be considering me for financial assistance, or making decisions relating to my educational plans in support of this application. If granted assistance, I also am willing to attend an awards ceremony, to write a letter of appreciation to scholarship donors, and to be interviewed by media representatives.


Signature	Date

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