Lavelle Leaders Award Application Form Name First Last Mailing Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneEligibility DeterminationProof of sponsorship by a vision-specific state agency such as the NYS Commission for the Blind (NYSCB), CT Bureau of Education and Services for the Blind (BESB), or NJ Commission for the Blind and Visually Impaired (CBVI) OR letter from a medical eye care provider indicating legal blindness will suffice.Documentation of Legal Blindness Upload - NOTE: File must be named: Last Name_Vision_documentationMax. file size: 64 MB.Legal Residency Status I attest that I am a legal U.S. resident.EducationCollege or UniversityselectCanisius CollegeDominican CollegeFairfield UniversityFordham UniversityLe Moyne CollegeManhattanville CollegeMarist CollegeMarymount Manhattan CollegeMolloy CollegeSeton Hall UniversitySt. John's UniversitySt. Thomas Aquinas CollegeCurrent or Most Recently Completed Year in SchoolselectJuniorSenior1st Year Graduate Student2nd Year Graduate Student3rd Year Graduate Student4th Year Graduate StudentExpected Date of Graduation Program of Study Current G.P.A. Current Unofficial Transcript Upload - NOTE: Files should be named: Last Name_transcriptMax. file size: 64 MB.EssayApplications must include an essay in Word format, 14 font, no longer than 3 pages in response to the following prompt: “Share Your Strength”. Drawing from your personal experience, describe how, and in what capacity, you developed leadership skills, and how such efforts have made a significant impact on your community. Be sure to include any obstacles you encountered and how you handled them. Feel free to mention any individual (mentor, teacher, relative) who might have had an influence on your development as a leader.Essay Upload - NOTE : Essay should be named: Last Name_EssayMax. file size: 64 MB.Letters of Recommendation (2)Two letters of recommendation from individuals who have worked with the applicant in a school, work, or civic capacity must be sent from Recommenders directly to Kate Morris ([email protected]) no later than May 31st. Letters of recommendation received from the applicant's email address will not be accepted. It is the Applicant's responsibility to request and track these letters. Please indicate the names and titles of individuals who will submit recommendations, below.Recommender 1 Name First Last Recommender 1 Title and/or Organiztion Recommender 2 Name First Last Recommender 2 Title and/or Organiztion Disclaimers1 - The Lavelle Fund reserves the right to change awards, amounts and eligibility criteria without prior notice. The Fund further reserves the right to not issue any Leader Awards in any given year if submissions do not meet our standards.2 - Information collected during the application process is shared only with the award selection committee for review and awarding purposes, and the Fund’s Controller to distribute the financial award to award winners.3 - To track scholarship tuition reimbursement payments and to ensure that each awardee only receives one scholarship, the Lavelle Fund will permanently retain the names and details of its annual scholarship winners. Additional electronic applicant records will be purged after the scholarship award selection process has concluded.4 - Scholarship award recipients authorize that their name and image may be shared publicly in Lavelle Fund communications and agree to participate in marketing activities as appropriate.5 - The Lavelle Fund is not required to report scholarship award funds to U.S. residents as income, either to the IRS or the student recipient, or to withhold taxes from scholarship payments. Federal tax laws consider it the student’s sole responsibility to know when income is taxable or not, and to report income accordingly on his or her personal tax returns. Consent(Required)I agree to the terms of the Lavelle Leaders Scholarship Disclaimers as indicated above. SignatureSelect student's signature format: I will sign using a mouse or stylus. I will sign using the keyboard. Electronic Signature - You are authorizing the use of this electronic signature by signing in the field below. Use your mouse or stylus.(Required)Electronic Signature -You are authorizing the use of this electronic signature by typing in the text field below.(Required) First Last Date A copy of this submission will be automatically sent to the applicant's email address provided above.EmailThis field is for validation purposes and should be left unchanged. Δ