8-31-16
Background Information:
College major or possible fields of interest: ______________________________
Future college plans: ______________________________________
Anything else you’d like to tell us about yourself?
I certify that the information I have provided on this application is true and complete to the best of my knowledge.
I understand that the information about me known to the Admissions and/or Registrar’s Office may be useful to
evaluate my eligibility for a scholarship and I authorize those offices to release information about me to the
Scholarship Office. I further authorize release of my application to third parties for the purposes of scholarship
consideration. I also understand that if I am selected as an Ava and Sam Guerrera Study Abroad Scholarship
recipient, I will also be required to write and submit an additional two-page essay (minimum) at the end of my
study abroad program summarizing my experiences and how the experiences have influenced my life. I also
understand the Scholarship Office will withhold $200 of the $2,000 award pending receipt of the essay. If I receive
an AIFS scholarship, I will provide the Study Abroad Office with my blog address and understand it will be posted
on its website. If I am selected for a scholarship award, I authorize release of autobiographical information for use
in publicity related to the scholarship program. I further agree that I will notify the Scholarship Office of any
changes (major, residence, etc.) which would affect my eligibility for a restricted award. Lastly, I agree that if I am
awarded a scholarship, I will send my “thank you” letter(s) to the donor(s) in care of the Santa Rosa Junior College
Scholarship Office.
______________________________________________ ____________________________________
Applicant Signature Date
Applications should be submitted to the Study Abroad Office in Room 1525 Emeritus Hall, SRJC Campus, no later
than Friday, Oct. 28, 2016.