Applicant’s Name                                                                                                                                                                

Address                                                                                                                                                                                

Phone Number                                                       Social Security Number                                                                     

What services did you receive from the SOS Shelter?                                                                                                  

When did you receive services?                                                                                          

Was your name different at that time?     Yes          No

If yes, please indicate what your name was                                                                           

Is your life currently free from abuse from any other individual?      Yes      No

If you received this scholarship, would you be willing to have your name publicly announced as a recipient? 
     Yes            No

Why do you need the additional support that would be supplied by this scholarship?                                               

                                                                                                                                                                                             
   Signature of Applicant                                                                                                                     Date