Scholarship Application Form

Scholarship Application - Applications are open! Fill out the form below to apply.

Cape West Rotary Club and Southeast Missouri State University Working Student Scholarships

Scholarship sponsor: Cape West Rotary Club
Please fill out all information completely where applicable.


First name
Last name
Southeast ID#
Email address
Current address
City:  State: Zip:
Primary phone
Is your permanent address the same as your current address?
Permanent address (if different)
City: State: Zip:


Current enrollment status: 
Degree and major you are pursuing:
Hours completed: As of:
Hours presently enrolled in:
University GPA:
University activities and honors:
Schools previously attended (please include school name, address, and dates attended):


Are you currently employed?  Hours per week: 
Gross pay per week: 
Place employed: 
Supervisor name:
Supervisor contact number:
Father's name
Father's address
Father's occupation
Father's income (from previous year)
Mother's name
Mother's address
Mother's occupation
Mother's income (from previous year)
Guardian or spouse name
Guardian or spouse address
Guardian or spouse occupation
Guardian or spouse income (from previous year)
How many people are dependent on the above income(s)?
Will there be a significant change in any of the above income(s)?
If yes, explain:
Describe below any other pertinent information concerning the financial assets and obligations of
your family that would be helpful in assessing your financial need for the scholarship requested.
What year, make and model of vehicle do you drive (if none, put "none")?


Please check any type of financial aid you will be receiving for the semester you are applying this scholarship.
Did you complete the FAFSA (Free Application for Federal Student Aid) for the current year?
Pell Grant  If yes, what amount? AFDC  If yes, what amount?
Veteran's benefits  If yes, what amount? Scholarships  If yes, what amount?
University stipend  If yes, what amount?  Other (please list types and amounts)
Provide a brief description of any special circumstances you feel should be considered by the scholarship committee reviewing your application.
By electronically signing this application, I certify that the information provided above is correct. I give Student Financial Services at Southeast Missouri State University permission to forward my completed application and the results of my Free Application for Federal Student Aid (FAFSA) to the necessary scholarship committees for review and to verify my grades, hours completed and enrollment status.
sign here
Today's date (MM/DD/YYYY): 
Click the button below to submit your information. If you are selected as a scholarship recipient, you will receive more information in the future.

Captcha Code