PLEASE MAKE A GENEROUS GIFT TO TWO TEN TODAY
so we can continue to touch the lives of shoepeople in need

Questions regarding your application? scholarship@twoten.org 800-346-3210 x1512

Pre-qualifying Questionnaire

Please complete the questions below to pre-qualify for the Two Ten Higher Education Scholarship. After you have answered all the questions, click the Submit button and follow the instructions. If you have any questions, please contact the Scholarship Department at 1-800-346-3210 x1512.

1. Please indicate who is employed in the footwear, leather or allied industries.
   

   	Parent (student's natural or adopted parent is employed in the above industries for a minimum of two years prior to January 1 and student is considered dependent.)
   	Step-Parent (same as parent explanation above)
   	Self (student is employed in the above industries at least 500 hours during the year prior to January 1)
   	None of the above

2. Name of footwear company you or your parent is affiliated with:
3. Your Date of Birth: (MM/DD/YYYY)
4. Are you a United States citizen or eligible non-citizen?
   

   	Yes
   	No

5. Will you enroll or be enrolled at an accredited college, university, nursing or vocational/technical school earning a two or four year undergraduate degree for the 2011-2012 academic year?
   

   	Yes
   	No

   How many semesters will you have completed by Spring Semester 2010?

6. Where did you first hear about the Two Ten Scholarship Program?   -- Please Select -- Employer Two Ten Scholarship Websites (Fastweb, Scholarship.com, etc.) Other
   
   Employer: -- Please Select -- HR/Benefits Manager or Your Supervisor Company Communications (email, newsletter, intranet) Scholarship Poster/Flyer 210 Representative Site Visit Company Health Fair Co-worker
   
   Two Ten: -- Please Select -- 210 Newsletter 210 Website Contact with 210 Representative Industry Event (tradeshow/networking event/annual dinner/golf outing) Industry Publication
   
   Other: