Please complete all the following fields and "Submit" when complete.
If you have any questions please email Julie Lowery at email@example.com
Preferred Method of Contact
University/College (Must be a California school)*
Graduation Date (mm/dd/yyyy)
If recent High School graduate
Experience (Work, community service, non-profit organizations, etc.)
Description of Activities:
Contact Phone (999-999-9999):
Application Topics (Select 2 of 4 below, 400 - 800 words each)*
1. How does studying Technology fit into your future career goals and passions?
2. Discuss a special accomplishment / attribute in technology that sets you apart from other applicants.
3. Describe how you would like to make a difference and how your college plans (and the Scholarship) can help you on your journey.
4. Tell us about you: Why did you choose Technology? Why is the scholarship important to you?
USE OF INFORMATION: The information and materials provided in this application and on Applicant's (“Applicant” shall mean the individual identified by name as set forth above and all other natural persons, businesses, legal entities, agents, representatives, employees, partners, corporate agents, or any other person acting or purporting to act for or on their behalf) behalf will be used by AWT (“AWT” means “Advancing Women in Technology,” a California nonprofit public corporation, the AWT Foundation, a California charitable organization, and all other natural persons, businesses, legal entities, agents, representatives, employees, partners, corporate agents, or any other person or purporting to act for or on their behalf) for the purposes of evaluating the Applicant and determining that all application criteria is met, creating a press release, and/or conducting research, providing educational materials or any other purpose not otherwise prohibited by law. Applicant’s participation confirmed by electronic signature herein below or “wet” signature submitted by fax, mail, e-mail, or any other method of transferring a printed image of this completed form with Applicant’s handwritten signature, constitutes permission for AWT to use Applicant’s information in the aforementioned manner and to share the Applicant’s information with any of its partners for purposes of scholarship fulfillment and future marketing programs. By my signature below, I consent to the use of such information for this purpose and hereby confirm and represent that I have obtained any and all authorizations, consents or waivers required for such use.
ELECTRONIC SIGNATURES. Any signature or initials (including any electronic symbol or process attached to, or associated with, a contract or other record and adopted by Applicant with the intent to sign, authenticate or submit such application or record) hereto or to any other certificate, agreement or document related to this transaction, and any application formation or record-keeping through electronic means shall have the same legal validity and enforce-ability as a manually executed signature or use of a paper-based record keeping system to the fullest extent permitted by applicable law.
USE OF PHOTO AND LIKENESS: By my signature below, I hereby consent that if selected to receive this award, I agree to my name, photos, likenesses, video, and/or images to be used in any media, including without limitation on the Internet and in social media, for advertising, promotional and publicity purposes in relation to this program without prior written consent or compensation but the photo will not be requested unless you are selected.
RELEASE: By my signature below, on behalf of myself, my parents, spouse and/or assigns, I hereby release, discharge, and hold harmless, AWT and the Board of Directors, mentors, employees, agents, successors, and representatives from any and all claims or damages arising out of, in any way, their participation in this program.
APPLICANT'S CERTIFICATION. In submitting this application, I certify that information provided is complete and accurate to the best of my knowledge and that the essay is my own work. I understand that I will be required by AWT to provide documentation to corroborate the above information in order to receive scholarship payments. I realize that failure to comply with a request will prevent me from being considered for scholarships and will result in the termination of the scholarship. Further, I certify that I meet the intent and criteria of the scholarship funds that I have applied for as stated in their guidelines. I realize that falsification of information will result in termination of any scholarship granted. I also certify that I do not fit in any of the categories listed below:
I further agree that if I become aware of any information that might indicate that this disclosure is inaccurate or that I have not complied with this policy, I will notify AWT immediately.
I hereby understand that if chosen as a scholarship winner, I must provide to AWT evidence of enrollment/registration at the post-secondary institution of my choice in the form of letters of admission, verified class schedules, cashed checks for tuition, or other proof of enrollment pursuant to AWT’s request, before scholarship funds can be awarded.
Signature* (Please type your name)
Signature of parent or guardian if under 18 years of age
Relationship to Applicant
Contact Information (Email or Telephone)