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
Date Of Birth
Place of Birth
Do you live with Parents? YesNo
If no, do you live with Relatives? YesNo
# of siblings-brothers
Education/Training To Date
Date of Graduation
What school or college do you plan to attend this coming year? List 1st, 2nd, 3rd choices.
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.
Honors and Awards
Scholarships or Grants (other than 100 Black Men of Jacksonville, Inc.)
Offices held in class or school clubs, organizations, etc.
Non-School Activities (e.g. church participation, hobbies, special talents, community services, etc.)
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
Please list below any special circumstances (i.e., outstanding medical/dental obligations, dependents not covered on Tax Forms, etc.) which may preclude parent’s/guardian’s ability to provide for college education.
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).