CREDENTIAL OR APPRENTICESHIP: QUALIFYING QUESTIONNAIRE Name* First Last Date of Birth: MM/DD/YYYY* Date Format: MM slash DD slash YYYY Email* Do you live in Benton County?*YesNoWhich status refers to you?*Single/Never MarriedDivorcedMarried but Legally SeparatedWidowedAre you a legal U.S. resident or resident with DACA status?*YesNoAre you your child's primary custodian or have joint custody?*YesNoHave you ever received a Bachelors Degree?*YesNoIs your child 18 years or younger, older than 18 and still in high school, or a severely disabled adult who lives with you?*YesNoPlease list your child(ren)s information below.*NameDate of BirthGender Ex. Joes Adams 12/03/2017 Male (Click the + sign to add additional children.)Is another adult living in your household?*YesNoIs the other adult living in your household your:*Parent/GuardianGrandparentSiblingIs anyone sharing household expenses with you?*YesNoPlease list the name and relationship of all of those sharing household expenses with you.*NameRelationship (Click the + sign to add additional children.)Do you receive assistance from any of the following? Please check box if so.* SNAP WIC AR Kids HUD TEA None of the Above Where did you attend High School? What year did you graduate? Or what year did you complete your GED?*Ex. Rogers High School 2015 Graduate or GED Graduation Year 2015Are you currently enrolled in school?*YesNoWhich school are you enrolled in?Crowder CollegeHarding UniversityJohn Brown UniversityNWACCNorthwest Technical InstituteMissouri Southern State UniversityPetraUniversity of ArkansasIf you are not currently enrolled in school which school are you planning on attending?What area of study do you wish to pursue?*Do you have a 2.0 GPA or higher?*Please insert GPAAre you a first generation college student?*YesNoHave you ever been convicted of a felony which would affect your ability to work in public education facilities, hospitals, or other positions of trust (this would include convictions whether expunged, or Act 346?*YesNoHave you ever been in the military?*YesNoMailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Cell Phone*Employer Name Employer PhoneTerm Start Date*How did you hear about SPSFBC?*Thank you for your interest in Single Parent Scholarship Fund of Benton County. Unfortunately, you do not qualify for our program at this time. Reasons for not qualifying vary and eligibility requirements are listed under the Qualifications tab on the website. If you feel you received this message in error or if you have further questions about the program and our qualifications please contact us at (479)254-8550. Our hours of operation are Monday – Thursday, 8:30am-4:30pm. Thank you for your interest in Single Parent Scholarship Fund of Benton County. You have passed the initial qualification questions and are a potential candidate for the SPSFBC program. Please hit the submit button to send your information to the Program Coordinator IMPORTANT NOTE: Qualifying Questionnaire does not guarantee acceptance into the program. You will be contacted by the Program Coordinator after your application is received to set up a pre-interview. Our hours of operation are Monday – Thursday, 8:30am-4:30pm.