Name:___________________________________

Address:________________________________________________________________

___________________________________e-mail __________________________

Phones: Home ______________________ Other ______________________________

The Mosaic Initiative is offering one-time scholarships for people who have been disabled by HIV/AIDS and, in the course of their journey, are readying themselves for employment. These scholarships will vary in amount from $250 to $1000, depending on the specific need, and can be used for either a training/certification class, or completion of academic coursework towards a degree.

In filling out this request, what is your goal or intention?

What have you done so far to work towards this goal? What would be the steps after this towards achieving the goal of employment?

What are the significant barriers you face/have faced?

In what capacity were you working before you became disabled?

What is the estimated cost for this educational pursuit?

Please include one letter of recommendation, from current/previous employers, instructors, case managers, or someone who can speak to your ability to identify and pursue goals.

In addition to this application, we will need verification from a medical provider regarding HIV/AIDS disability status. This information will be shredded upon confirmation.

Please return this material to:

The Mosaic Initiative

102 N. Cross St., #4B

Wheaton, IL 60187

The Deadline for this Application is November 1, 2006

Decisions will be made by November 10, 2006

You will be notified by November 15, 2006

Thank you for your interest.