1. Student’s cumulative GPA for the current school year _ __ out of what scale (e.g. 3.0 out of 4.0) _ _ .
2. Estimated cost for tuition, books, and other tuition-related expenses (excluding housing) for the 2005-2006 school year $ .
3. List the name and the amount of scholarships/grants (excluding loans) the above student
is receiving, or anticipates receiving, for the 2005-2006 school year.
4. Total of scholarships/grants for the school year $
5. Considering any scholarship/grant funds awarded and restrictions placed on the expenditure
of those funds, what is the “tuition balance” for the school year? (Line #2 minus Line #4) $
6. If a Xerox Technical Minority Scholarship is awarded to this student, the check will be mailed directly to your institution.
What is the name, title and mailing address of the individual to whom the check should be mailed? Checks will be sent overnight. The
overnight carrier will not accept post office box numbers.
The signature, stamp, or seal below verifies the above student’s full-time enrollment, scholarship, and GPA.
Certified by: Title: Date:
Note: Contact persons above must be authorized to release student information.