WestCare Arizona

Application for GED Scholarship

1. PERSONAL INFORMATION Applicant Name:
Age:
Phone Number:
Mailing Address:
City:
State:
ZIP:

2. REFERRED BY (CHOOSE ONE) MCC Instructor:
WIA Instructor:
Probation Officer:
Parole Officer:
DES:
Self-Referred:

3. PRE-TESTING

Copy of GED-timed pre-testing scores attached?

Yes:
No:

4. BACKGROUND INFORMATION

The following information is obtained for reporting purposes only:

Male:
Female:
Race:

5. EMPLOYMENT STATUS

Check all that apply:

Employed Full-Time
Employed Part-Time
Unemployed
Student
Disabled
Veteran

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