Apply Online

Before you start filling in the application, be sure to have name and contact information of personal and professional references, as well as volunteer work program contact information. The application will take approximately 10 to 15 minutes to complete online. Please write your 500-word essay and save it in a separate document before submitting.

1. Identifying Information

* Indicates required field

First and Last Name of Applicant *

First

Last

Date of Birth (MM/DD/YYYY) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

2. Incarceration Information

Start Date of Incarceration (MM/DD/YYYY) *

Location(s) of Incarceration *

Release Date from Incarceration (MM/DD/YYYY) *

3. Volunteer/Community Work

Name of Program or Non-Profit *

Purpose of Program or Non-Profit *

Position Held or Work Done *

Name of Supervisor *

Program Address *

City *

State *

Zip *

Supervisor or Program Contact Number *

4. References (must provide phone and/or email)

Reference #1 (First and Last Name) *

Email1 *

Phone1 *

Reference #2 (First and Last Name) *

Email2 *

Phone2 *

Reference #3 (First and Last Name) *

Email3 *

Phone3 *

5. Essay: The contribution I wish to be to my community is....

In no more than 500 words, please explain how you expect to demonstrate leadership in your community. Please be as specific as possible. You can copy and paste your essay in from another document OR you can upload your document in Word or PDF format.

500-word Essay (if not using Upload File) *

Ready to submit? Please make sure all required fields are filled in. We're looking forward to receiving your application!

Submit

Mahin Bina Memorial Scholarship Application

1. Identifying Information

​2. Incarceration Information

​3. Volunteer/Community Work

4. References (must provide phone and/or email)

5. Essay: The contribution I wish to be to my community is....

2. Incarceration Information

3. Volunteer/Community Work