RSA Application Form Page

Legal Name:

[Last, First, Middle]

Social Security Number _____________________________________________________

Address: ________________________________________________________________


Telephone: ______________________________________________________________

____ Vocational Evaluation
____ Rehabilitation Counseling
____ Rehabilitation Counseling – Online

Please check the appropriate response to the following questions:

  1. Upon completion of your program, do you accept the employment obligation to seek and maintain employment in a state vocational rehabilitation agency or in a related agency providing services to individuals with disabilities under a service agreement with the designated state vocational rehabilitation agency?

    ____ Yes ____ No


  1. Have you or will you accept payment of educational allowances from any other federal, state or local public or private nonprofit agency if that allowance is conditioned on an employment obligation that conflicts with the employment obligation as described in the application materials?

    ____ Yes ____ No


  1. Are you a United States citizen (if yes, specify state of residency: ________) or national?
    Are you a permanent resident of the Republic of the Marshall Islands, Federated States of Micronesia, Republic of Palau, or the Commonwealth of the Northern Mariana Islands?
    Are you a lawful permanent resident of the United States?
    Are you in the United States for other than a temporary purpose with the intention of becoming a citizen or permanent resident of the United States?
    (If yes, documentation will be required if you are awarded a scholarship.)

    ____ Yes ____ No
  1. Are you in default on a debt to the federal government under a nonprocurement transaction?

    ____ Yes ____ No
  1. Have you or will you apply for financial aid? If yes, please specify source(s). (Note: 40% of our awards must be based on financial need.)

    ____ Yes ____ No
  1. Are you receiving support from a state vocational rehabilitation agency (DVR)?

    ____ Yes ____ No If yes, specify amount of funding: _____________________


Please describe your career objectives and interests. Relate your career goal to the purpose of the RSA scholarship.

(Attach additional pages, if necessary.)






Financial Need Consideration (optional):

I have or will submit the Family Financial Statement to American College Testing (ACT) for analysis and wish to be considered for the funds reserved for students with demonstrated financial need. I understand if the ACT Family Financial Statement does not indicate need, I will also be considered based on the other priorities stated in the application materials. I authorize the RSA Project Director to have access to the analysis of the ACT Family Financial Statement through the Financial Aid Office, University of Wisconsin-Stout.

Applicant's Signature _______________________________________ Date ______________
(To authorize access to Family Financial Statement analysis only)

I certify that I am eligible to receive an RSA Scholarship and that the information in this application is true and complete to the best of my knowledge. I understand that inaccurate information may affect my ability to receive an RSA Scholarship. If I am awarded an RSA Scholarship, I expect to be subject to its terms and conditions as described in the RSA Scholarship Application and in the 1986 and 1992 Amendments to the Rehabilitation Act of 1973 (P.L. 99-506 and P.L. 102-569).

Applicant's Signature _______________________________________ Date ______________

The following information is voluntary. This information will not be used as part of the admission screening process. It will be used for general reporting to the RSA and in identifying applicants of under-represented groups which receive priority in the awarding of the scholarship.Race/Ethnic

____ White, not Hispanic
____ Black, not Hispanic
____ Hispanic
____ American Indian or Alaskan Native
____ Asian or Pacific Islander


____ Yes ____ No
If yes, please give specific details with regard to the severity and percentage of involvement. Attach verification, if possible.


____ Male____ Female


____ 49 or under____ 50-64 ____ 65 and over