All requested information MUST be furnished completely. Failure to supply any part of the requested information including a copy of the previous year’s Tax Form voids application from consideration. Applications and other required information must be submitted or postmarked no later than midnight, March 31st. If mailing a hard copy please return to: 100 Black Men of Jacksonville, Inc., P.O. Box 2065, Jacksonville, Florida 32203

General Information

Date Of Birth
Place of Birth
Mobile Phone
Do you live with Parents? YesNo
If no, do you live with Relatives? YesNo
# of siblings-brothers
Mother or Legal Guardian


Education/Training To Date

High School
Date of Graduation
Proposed Major
Describe briefly your plans and your future vocational or professional objectives. Give any
information that you feel will be helpful to the committee in assessing your situation and your need
for financial assistance.

School Activities

Honors and Awards
Scholarships or Grants (other than 100 Black Men of Jacksonville, Inc.)

Work Experience

Describe your work experience (part time, full time, and/or vocation jobs).

Declaration of Financial Need

(Must be accompanied by copy of current FAFSA EFC STATEMENT)

Enter father and mother's total yearly wages before deductions.
Enter father and mother's total yearly income from other sources.
Please attach your FAFSA EFC STATEMENT

Other Attachments

Photograph of Applicant

A recent black & white photograph of Applicant (not a snapshot) for publicity purposes
Must be head and shoulder at least 2” x 2 1/2”.

Supporting Documents

The following required information must be mailed by the person furnishing this information, under separate cover, directly to: 100 Black Men of Jacksonville, Inc., P.O. Box 2065, Jacksonville, Florida 32203. Forms and instructions for supporting information can be found on the J100 Scholarship Center page and will also be emailed when a completed application form is submitted.

All information received will be held strictly confidential and will be kept for the Scholarship Committee’s use only.

  • Confidential Form No. 1 from minister, doctor, or close friend of the family having knowledge of family’s financial situation.
  • Confidential Form No. 2 from counselor, dean, principal, or person acting in this capacity in
    high school. Must include Rank in Class which shows total number of graduates, and Grade Point Average utilizing grades in all subjects taken (including physical education) in grades 9, 10, 11, and the first semester of 12.
  • Confidential Form No. 3 from employer or other person outside of school who will recommend applicant for scholarship.
  • A complete transcript of the applicant’s educational history from grade 9 to and including the first semester of grade 12. Also accompanying this transcript should be college entrance exams scores (SAT, ACT, PERT).

Submit Application

I hereby make application for one of the 100 Black Men of Jacksonville, Inc., Scholarships and submit the above information to assist the Scholarship Committee in evaluating my candidacy, and certify that:

  • All the information submitted in this application is true and correct;
  • I will use any funds received from the J100 only for the purpose of paying expenses for my college education;
  • I will notify the J100 immediately if there should be any interruption in my plans for continuing my education this coming year.