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Name *

Email *

Phone *

Are you male or female? *MaleFemale

Are you 18 years of age or older? *You may still apply if your under 18 years of age. However, you must be over the age for compulsory attendance in your state to receive a scholarship.YesNo

Do you have a HS diploma or GED? *YesNo

Please upload a copy of your high school transcript. *Your application will be marked incomplete without this document.

No file chosen

Are you able to pass a DPS (Department of Public Safety) background check? *One of the requirements to receive an award is to be able to obtain a Fingerprint Clearance Card which requires a DPS background check.YesNo

Have you ever applied for a Fingerprint Clearance Card and been denied? *YesNo

Do you have a US State ID?YesNo

Please upload a copy of your US State ID.Your application will be marked as incomplete without this document.

No file chosen

Do you require financial assistance to help with the cost of your tuition or student loans? *YesNo

Do you require any special accommodations that is qualified under the ADA to complete your program? *YesNo

Which Scholarship are you applying for? *Gold ScholarshipSilver ScholarshipBronze Scholarship

Select the appropriate box that identifies your current annual income. *An individual who makes $15,650 or lowerI have a family of 2 who makes 21,150 or lowerAn individual who makes 16,000 - 25,000 per yearAn individual who makes between 25,000 - 40,000 per yearI make over 40,000 per year

Have you already applied to the school of your choice? *One of the requirements to receive an award is to apply for funding through the school where you want to attend.YesNo

What school are you trying to attend ? *Arizona's Virtual Pharmacy Tech SchoolArizona Western CollegeNorthern Arizona UniversityGateWay Community CollegeMy choice is not listed

Are you unemployed? *YesNo

Consent *

AZOPTA (Arizona Online Pharmacy Tech Association) will use the information you provided to conduct a background check to determine the validity of your application.

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