Name ___ First ___ MI ___ Last ___

Home Address ___ Street City State Zin

Street

City

ty State Zip

Campus Address _____ Cell Phone No. _____

Campus Email _____ Personal Email _____

Date of Birth _____ Male 2026-2027 Classification _____

Major___ Current GPA ___

Father/guardian _____ Occupation_____

Mother/guardian _____ Occupation_____

Number of siblings at home ___ Number in college ___

List activities that you have participated in: (If necessary, attach a separate sheet):

☐ College/University extracurricular activities and positions of leadership:

<div style="text-align: center;"><img src="imgs/img_in_image_box_9_17_2281_186.jpg" alt="Image" width="99%" /></div>

Community service/volunteer activities and the number of hours of volunteer service:

Special awards and recognitions:

□ List work/intern experience and the number of hours per week:

NEED REQUIREMENT: On a separate sheet, provide a typed explanation of why you need the PAS Fund assistance. Funds will not be released until financial need is confirmed.

With submission of this application and by my signature below, I hereby acknowledge and consent that all information contained is accurate and will be confirmed and shared by Kentucky State University to the PAS Fund Committee for eligibility and qualification purposes.

Student signature _____ Date _____

Financial Aid signature _____ Date _____