Xerox technical minority scholarship application

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TO STUDENT: Please complete the following information based on the current school year. All applicants must be full-time students enrolled at a four-year institution to be eligible. Deadline for submission of this application, including resume, should be postmarked before September 15, 2005. Be sure to verify that your institution has properly and fully completed the bottom portion of this form. Note: Spouses and children of Xerox employees are not eligible for this program. NO APPLICATION WILL BE PROCESSED WITHOUT APPLICANT RESUME ATTACHED.

Last Name, First Name, Middle Initial


Social Security Number




School Street Address City, State, Zip School E-mail Address School Phone (Area Code)


Home Street Address City, State, Zip Home E-mail Address Home Phone (Area Code)


US Citizen or Permanent Resident?  Yes  No

 Black  Native American/Alaskan

 Asian/Pacific Islander  Hispanic



Name of 4-year

Institution Attending

Cumulative GPA (or High School GPA, if Freshman)

Scale (e.g. 3.0 out of 4.0)

Expected Degree


Major Field of Study

Expected Date of Graduation






Are you currently (or were you ever) a Xerox Technical Minority Scholarship recipient?  Yes  No

If yes, what year?      

Have you ever worked at Xerox?  Yes  No If Yes, what Business Group and year?      

Career Interests (Briefly state your short and long-term objectives. Feel free to use the back of this form.)


Applicant’s signature DATE      

My signature above indicates that I authorize school officials to release the below information to The Document Company, Xerox for inclusion in my application for the Xerox Technical Minority Scholarship.

TO INSTITUTION: Please complete the following information pertaining to the above student for the current school year. If your institution prefers to submit other verification forms, please insure the following information is included. Timely and accurate response is critical for the student to be considered for this scholarship.

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:      
Telephone:       Fax:      
Note: Contact persons above must be authorized to release student information.

Please forward completed form to

Xerox Technical Minority Scholarship Program

150 State Street; 4th Floor; Rochester, NY 14614

postmarked before September 15, 2004

Revised: 4/02

*Applications may be obtained on our web site (

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