SAMPLE APPLICATION Eligibility
You are eligible to apply for the Washington State Opportunity Scholarship if you answer YES to each of the
statements below. If you have any questions, please email [email protected] or call 1-877899-5002.
1. You have received or will receive your high school diploma from a Washington state high school, or a GED
from the state of Washington by June, 30 2014.
2. You are a Washington state resident, (as defined in RCW 28B.15.012).
Yes, I am a Washington state resident
3. You will be enrolling as a first-year college student, as a sophomore or entering your first tem as a junior for
the fall 2014. Please note: If you will be a second-term junior or college senior in fall 2014 you are not eligible.
4. You will be pursuing an eligible high demand major (by alphabet; by category) in science, technology,
engineering, math (STEM) or health care. Please note: If your major is not on the list linked above, you are not
eligible to apply.
5. You will complete your first bachelor’s degree, (i.e. four-year degree), at an eligible Washington state
college/university. Please note: If you will be attending a public community or technical college in fall 2014 that does
not offer a four-year degree in your eligible high demand major you must be planning to transfer to one of the four-year
colleges/universities referenced above by fall 2016.
6. Your cumulative grade point average (GPA) through fall quarter/semester 2013 must be a minimum of 2.75
(on a 4.0 scale). Please note: If your college/university or high school does not provide GPA, or you received your GED,
please answer "yes" and your academic progress or score will be verified during the application review process.
7. You will enroll full-time (at least 12 credits per quarter/semester) every term during the 2014-15 academic
Yes, I will enroll full-time every term
8. You are eligible to file and will submit the 2014-15 Free Application for Federal Student Aid (FAFSA) at
www.fafsa.gov by February 24, 2014.
Yes, I have filed or will file my FAFSA by February 24, 2014
9. You meet the total family income requirement (adjusted gross income plus all untaxed income) for 2013
based on this chart. Please note: If you qualify to submit the FAFSA as an independent student, the family income
amounts are those reported by you (including spouse and children, if applicable) rather than your parents. Dependent
students must use their parent/guardian’s income.
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Date of Birth
Social Security Number
Please note: If this number does not
match the SSN on your filed FAFSA,
your application will not be
Preferred Phone Number
Type of Phone Number
Secondary Phone Number
Type of Phone Number
1605 NW Sammamish Rd
Please note: Email will be the primary
means of communication. Therefore,
please use a valid address that you
check regularly. If it changes notify us
promptly. Please make sure
[email protected] is
an approved sender – you may need
to check your spam settings.
Race and Ethnicity Identification*
Your answers to the following questions will allow the program administrator to report requested information to
the Washington State Opportunity Scholarship Board, the Washington State Legislature and other interested
parties such as the Washington Student Achievement Council and private donors. *These questions are not
required and the answer will not be considered for selection of this scholarship.
NOTE: The following questions adhere to the U.S. Department of Education Standards for gathering
information about a student's race and ethnicity and use the following guidelines:
American Indian or Alaska Native (a person having origins in any of the original peoples of North and
South America, including Central America, and who maintains tribal affiliation or community
Asian (a person having origins in any of the original peoples of the Far East, Southeast Asia, or the
Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan,
the Philippine Islands, Thailand, and Vietnam)
Black or African American (a person having origins in any of the black racial groups of Africa)
Native Hawaiian or Other Pacific Islander (a person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands)
White (a person having origins in any of the original peoples of Europe, the Middle East, or North
Are you of Hispanic/Latino descent (a person of Cuban, Mexican, Puerto Rican, South or Central American, or
other Spanish culture/origin, regardless of race)?
Additionally, what race(s) do you consider yourself? Regardless of your answer to the previous question,
please mark the following box(es) to indicate what you consider yourself to be.
American Indian or Alaska Native
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High School Diploma
I have or will receive my high Washington State High School
school diploma from
Washington State High School Issaquah High School
from which you received or will
receive your diploma
Month of high school diploma or 6-June
Year of high school diploma or 2013
I am currently Graduated High School - Enrolled in College
Where are you currently enrolled? University of Washington-Seattle
Is that college/university on a Quarter
quarter or semester system?
At the end of fall term 2013, how 15
many college credits have you
completed? In your total, please
count ALL college credits
completed at all colleges you
Please note: If you will be a second-term junior
or college senior in fall 2014 you are not
Expected completion date of first bachelor’s degree
Month 6 - June
Parent(s)' Education Level
What is the highest level of Some college, no degree
education completed by your
parent or guardian(s)?
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Grade Point Average
Your cumulative grade point average (GPA) through fall quarter/semester 2013 must be a minimum of 2.75 (on
a 4.0 scale).
If you have not yet graduated from high school, enter your high school cumulative GPA through fall
quarter/semester 2013. If you are a Running Start student check with your high school to ensure that
your Running Start credits for fall quarter are included.
If you are currently enrolled in college/university, report your college/university cumulative GPA through
fall quarter/semester 2013. Please note: If your most current GPA is from The Evergreen State College
fall 2013 please select The Evergreen State College from the drop down menu below and your
academic progress will be verified with the college.
If you have graduated from high school, but have not yet enrolled in college, enter your high school
If you graduated from high school, attended college/university, but are not enrolled fall quarter/semester
2013, enter your cumulative GPA from the college/university from which you earned the most credit.
If you received your GED, enter the score.
My GPA is from College Transcript
My GPA is 3.84
Please provide GPA through two decimal
eligibility points, e.g. 3.12.
Your College or University Enrollment Plans
Name of Washington college or University of Washington-Seattle
university where you will be
enrolled during the fall 2014
Will you be attending Full-time (12 or more credits each term)
Your Eligible Program of Study
Select the one program Computer Science
of study that best describes
your educational plans.
Your Academic Major
Select the one intended or actual eligible high demand major (by alphabet; by category) that best describes
your academic plans.
Your eligible high demand Major Computer Engineering, General-14.0901
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Extracurricular, Personal, and Volunteer Activities
List your top three extracurricular, religious, community, family activities and hobbies. Include specific events
and/or major accomplishments that would demonstrate your interest in science, technology, engineering, math
(STEM) or health care.
1. Activity Name Technology Club, Issaquah High School
Positions held, honors won, or Club founder and president
Dates of activity
Total hours spent on this activity 120
for the timeframe listed above
2. Activity Name Science Tutor, UW
Positions held, honors won, or Tutor
Dates of activity
Total hours spent on this activity 30
for the timeframe listed above
3. Activity Name Basketball
Positions held, honors won, or Varsity, Captain
Dates of activity
Total hours spent on this activity 360
for the timeframe listed above
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Paid Work Experience/Student Income Information
List the top two jobs, (including summer employment), you have held during the past three years.
1. Specific job and nature of work Cashier
Dates of employment
Approximate # of hours spent per 40
2. Specific job and nature of work
Dates of employment
Approximate # of hours spent per
(Sample application continued on the next page)
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Your Free Application for Federal Student Aid (FAFSA) or Student Aid Report (SAR) Information
To answer the following questions you will need to have the information from your 2014-15 FAFSA or from
your 2014-15 SAR that you receive from the U.S. Department of Education after filing the FAFSA. Reminder,
the FAFSA needs to be submitted by the deadline of February 24, 2014 to be considered for this scholarship.
Please let us know whether you completed the FAFSA as a dependent or an independent student. (You are a
DEPENDENT student if your parent(s) were required to provide financial information when you completed the
2014-2015 FAFSA. You are an INDEPENDENT student if your parent(s) were NOT required to provide
financial information on the 2014-2015 FAFSA.)
I completed the FAFSA as: A dependent student
The financial information provided below is: Estimated, and I will file my FAFSA by February 24, 2014
Provide the following information on Household Size and Total Family Income as reported on the 2014-15
FAFSA or SAR.
1. Household Size 4
Dependent students should enter line 73 from the
Independent students should enter line 95 from the
2. 2013 Adjusted Gross Income 84263
Dependent students should enter line 85 from the
Please note: If your parents did not file taxes, you must
include any income that was reported by them on the
FAFSA/SAR lines 88 and 89.
Independent students should enter line 36 from the
Please note: If you are an independent student and you (and
your spouse if married) haven't filed taxes, please enter your
(and your spouse’s, if married) income. This will be the total
of FAFSA lines 39 and 40.
3. 2013 Untaxed Income 2000
Dependent students should enter lines 94a-94i from the
Independent students should enter lines 45a – 45j from the
Maximum Family Income Requirements to Apply
Total Family Income (adjusted gross income plus all untaxed income) for 2013 cannot exceed this amount
listed in this chart for your family size.
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A minimum of 150 and a maximum of 300 words are required for the essay question before the application can
be submitted. We strongly recommend you do the following:
Read the question first
Outline your response before you begin writing
Write a draft of your essay. If it’s easier for you, you can write it in Microsoft Word and paste it into the
Share a draft with a teacher or relative to review
Describe your interest in the science, technology, engineering, math (STEM) or health care fields; and the
consequent activities, coursework, and/or hobbies in which you’ve been involved that demonstrate your
Ever since I was young I've known I wanted to work with computers.
This led me to start the Technology Club at my high school. I knew I
wanted to get more students at my school involved in technology.
I've demonstrated my interest first by taking the classes I knew I'd
need to get into college. I have also taken the most challenging math
classes and science classes at my high school, including AP
Calculus and AP Biology. I volunteer at the local library teaching
people to use computers.
Now that I'm attending UW, I volunteer as a science tutor. I am
planning to major in Computer Engineering and to pursue my dream
job: working at Microsoft.
(Sample Application continued on the next page)
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Instructions to Mail your Official Transcript
Please submit the transcript required based on your current enrollment status:
If you have not yet graduated from high school - You must submit an official high school transcript,
showing all of your classes through fall quarter/semester 2013 and it must include your cumulative
GPA. If you are a Running Start student check with your high school to ensure that your Running Start
credits for fall quarter/semester are included. You may need to request an official transcript from your
high school a couple of weeks in advance, so be sure to plan ahead.
If you are enrolled in college/university - You must submit an official transcript from your
college/university, showing all of your classes through fall quarter/semester 2013 and it must include
your cumulative GPA.
If you have graduated from high school, but have not yet enrolled in college - You must submit an
official high school transcript.
If you have graduated from high school, attended college, but are not enrolled fall quarter/semester
2013 - You must submit an official transcript from the college/university where you earned the most
credit, showing all of your classes through fall quarter/semester 2013 and it must include your
If you received your GED - You must submit a copy of your official GED score.
Please mail your transcript to:
College Success Foundation
Washington State Opportunity Scholarship
1605 NW Sammamish, Road, Suite 200
Issaquah, WA 98027
Your transcript must be postmarked by February 24, 2014 and you must have filed the FAFSA by February 24,
2014 for your application to be considered complete.
I will mail my official high school or college transcript to the College Success Foundation by February 24, 2014
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By my electronic signature on this form I promise that:
All of the information provided in my application is complete, current and accurate to the best of my
All of the information I have provided from my 2014-15 Free Application for Federal Student Aid
(FAFSA) or from my Student Aid Report (SAR) is complete, current and accurate.
By my electronic signature on this form I understand and agree that:
The information submitted in this application may be reviewed by the College Success Foundation
(CSF) staff, approved consultants, college staff or other approved volunteers for the purposes of
selection and or verification of information provided by me.
All information, including but not limited to: GPA, college or university enrollment, program of study,
actual or intended academic major, FAFSA household size and FAFSA income information is subject to
review or verification by any colleges or universities I may be attending during the period of the
scholarship, and by the Washington Student Achievement Council (WSAC) or their successor.
If at any time information provided in this application is found to be false or inaccurate, it is sufficient
cause for rejection or dismissal from the scholarship program.
By my electronic signature on this form I consent to:
Authorizing all information now approved for release to be transferred to another organization should
another organization other than CSF, the current program administrator, be later named as the program
administrator for this scholarship.
Authorizing the use of any and all information from this application in connection with CSF research and
evaluation activities. This includes my academic or financial information as long as this will not be made
available to the public in a form that would allow me to be identified. Stated differently, application
information may be made available to the public in an aggregated form, however, such as an average
or a total for a group of students.
Authorizing any college or university that I may attend while receiving the Washington State
Opportunity Scholarship to release to the program administrator (CSF) information including, but not
limited to: my academic records, transcripts, program of study, academic major, state residency,
financial aid, information from my FAFSA and any other pertinent information needed by CSF, both
while I am a student and after I am no longer attending, in order to manage and report on this program.
Authorizing the Washington Student Achievement Council, or their successor, and the program
administrator (CSF) to share information about but not limited to: my application, scholarship decision,
financial aid received, FAFSA information and academic information, for as long as necessary to
manage and report on this scholarship.
If you are selected for this scholarship, the program administrator may (1) release your name and the
name of the college or university you are attending to interested parties such as news media, school
districts, governmental agencies, and legislative personnel for the purpose of recognizing the
accomplishments of scholarship recipients, and (2) use my name, picture, or likeness (the “Likeness
Materials”) for any program or CSF purpose.
I waive (1) any rights I may have in connection with use of my information or the Likeness Materials,
including any right to own, inspect or approve the form, media or manner of use and (2) any liability
resulting from the use of my information or the Likeness Materials. If I am selected as Program
participant, I will, upon CSF’s request, sign additional releases in form and substance acceptable to
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By typing your name below, this will serve as your electronic signature for the agreement/consent section.
Applicant Agrees Yes
Applicant First Name John
Applicant Last Name Smith
If you are under 18, your parent/guardian needs to sign.
I am under 18 No
How did you learn about the Washington State Opportunity Scholarship? Please select all that apply.
My college or university
My high school guidance counselor or teacher
Announcements via Facebook
Announcements via Instagram
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