2016 Educational Scholarship Application

Applicant Information Date Received: _____________________

Name: _________________________________ _______________________________ _________________________________ Last Middle First

Mailing Address: ___________________________________________________________________________________________ Number & Street

____________________________________ _________ ____________ _____________________________________________ City State Zip E-mail Address

Telephone Number: __________________ Cell: _______________________ Date of Birth: ________ /________ /________ Month Day Year

For which of these organizations are you a client? (Check all that apply.)

Affordable Housing Clearinghouse OC Community Housing Corporation Fair Housing Council of OC

Education

Status as of September 2016: (Check one) Community College University/State College Trade School

Expected graduation year: ____________ Current GPA: ______________

Are you currently receiving monetary funding toward this goal from another source? Yes No If so, please list the source and amounts received. (Please attach answer to application.)

Need-Based Question: Please attach a letter, explaining in 250 words or less, why you are deserving of this scholarship. Be sure to indicate the hardship/need for the scholarship.

Essay Question: Please attach a one-page essay detailing how your household benefitted from services received by Affordable Housing Clearinghouse, OC Community Housing Corporation, and/or Fair Housing Council of OC.

By signing below, I certify that all of the information on this form is true and complete to the best of my ability. If Affordable Housing Clearinghouse, OC Community Housing Corporation, or Fair Housing Council of OC requires transcripts, financial aid or proof of enrollment information or receipts of purchased books, I agree to present all information as needed within a timely manner. In the event that I do not utilize the scholarship towards my educational goals or it has been determined that I have falsified documents, I promise to fully repay the full amount of the scholarship awarded.

_________________________________________________________ _______________________ Applicant Signature Date

Internal

Only:

THIRD PARTY MULTIMEDIA RELEASE FORM

By submitting original works such as photography, media, artwork, writings, articles, essays, short

stories, or other original works etc. to Clearinghouse CDFI, Website or other Media outlets, you are

agreeing to the terms stated in this media release form:

a) I understand that I am giving Clearinghouse CDFI the unrestricted right and permission to copyright

and edit, use, re-use, and publish the works submitted.

b) In compliance with the Copyright Revision Act of 1976, by signing this form, I hereby state that I am

the sole owner of the work submitted, that the work is original, that the use of these images or

materials does not infringe any third party rights and is not otherwise unlawful, and that I have the

powers to grant such rights.

c) I understand that I am relinquishing any right to examine or approve the completed product that may

be used in any Clearinghouse CDFI publications, website or other media outlets.

d) I understand that no compensation will be forthcoming from Clearinghouse CDFI or any other

publications, website or other media outlets for these materials.

e) I do further release and discharge and will compensate Clearinghouse CDFI and its officers,

employees, agents and volunteers from any and all costs, charges, damages and complaints for using

such work.

Clearinghouse CDFI will make every effort in good faith to ensure that all work submitted is

utilized indiscriminately and without misrepresentation.

List File Names:

Complete All Fields Below:

________________________ ______________________________ ____________________________

(Print Name) (Company Name) (Title)

______________________________________________ _____________________________

(Signature) (Date)

PLEASE RETURN THIS FORM TO CLEARINGHOUSE CDFI BY ONE OF THE FOLLOWING METHODS:

Email: marketing@clearinghousecdfi.com, or

Please call (949) 528-3287 with any questions or concerns. Thank you.