All requested information MUST be furnished completely. Failure to supply any part of the requested information voids application from consideration. Applications and other required information must be postmarked no later than midnight, May 16th. 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
Living Accommodations HomeCampus HousingOther
Mobile Phone
Father or Legal Guardian


Education & Training

(List last or current college term)

What college or university do you plan on attending this coming year?
Give any information which you feel would be helpful to the Scholarship Committee in assessing your situation and your need for continued financial assistance. (Family financial hardship, medical, unusual circumstances)

College Activities

Honors and Awards

Non-School Activities

(i.e. volunteerism, music study, church activities, sports, hobbies, etc.)

Work Experience

Describe any part-time and/or summer jobs while attending school, or full-time employment. Describe significant duties and state average earnings on each assignment.
Enter applicant's current year's earnings:



Supporting Documents

A complete transcript of applicant’s college work must accompany the application form. If transcript is not attached, application will not be reviewed. Transcript may also be mailed under separate cover to the following address: 100 Black Men of Jacksonville, Inc., P.O. Box 2065, Jacksonville, Florida 32203

NOTE: If school uses a pass/fail system, grade evaluation is required.

Parent/Guardian Income

Parent or Guardian Income Range (Please Check one)

Career Goals

Please list in twenty-five words or less your career goals

Submit Application

I hereby make application for a J100 Scholarship Renewal award and
submit the contained information to assist the Scholarship Committee
in evaluating my candidacy and certify that:

  • All information submitted in this application is true and correct.
  • I will use any funds received from the J100 only for the purpose of paying related 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.