Employee/ Dependent
Scholarship Application
Student Information:
Please complete the following:
 Mr.  Mrs.  Ms.
First Name
Middle Initial
Last Name
Address
Street
City
Social Security Number
State
Zip
STC Student ID: A
Telephone #
Semester:
Are you an Employee or a Dependent of a Lacks Employee?

Employee

Dependent
If you are a dependent of an Employee, please provide their full name:
Employment Verification
To be completed by LACKS Human Resources Office.
I,
First Name
Last Name
Title/Position
Certify that the above mentioned Employee/Dependent is eligible to receive funding from LACKS:
(please check)
 Employee Scholarship

Dependent Scholarship
HR Representative Signature
Date
Telephone #
Email
I affirm that the information submitted on this form is completed and accurate, to the best of my
knowledge.
Student Signature
Date
No person shall be excluded from participation in, denied the benefits of, or be subject to discrimination under any program or activity sponsored or
conducted by South Texas College on the basis of race, color, national origin, religion, sex, age, veteran status, or disability.