Internet Form Instructions: You may either download this form in PDF format*, fill it in by hand, and mail it; or fill it in here, then print, sign, and mail it. This form is not "submit-able" due to the need for a signature.
* You will need Adobe Acrobat Reader 5.0 or higher. If you do not have it, it can be downloaded free of charge from by clickinghere.
Please refer to the general information section of the scholarship booklet to assist you in completing this application. This form may be photocopied and used to apply for the majority of scholarships in this booklet. Use additional sheets if space provided is not sufficient.
Name of Scholarship:
Applicant Name: Last:
First:
Middle:
Address: Street:
City:
State:
Zip:
Telephone:
Social Security #:
Birth Date:
Email:
High School Attended:
COLLEGE: Name of the college for which financial aid is requested. If unknown, please list in the order of preference where applications have been sent.
School
Location
What course of study do you plan to pursue?
TRANSCRIPT INFORMATION: Please include an official copy of your latest academic transcript in addition to the following information:
ACT SCORE:
GPA:
Eligible for the free or reduced lunch program?
YES NO
If yes, did you quality for the FULL program or the PARTIAL program?
MEMBERSHIP INFORMATION: If employment or membership in an organization is an eligibility requirement for this particular scholarship application, please describe how you qualify for the scholarship.
LIST PRIOR WORK EXPERIENCE: If you have never been employed, please explain the use of your summer time.
Employer
Title/Work Performed
Date
STUDENT AWARDS, SCHOOL INVOLVEMENT AND COMMUNITY SERVICE: List extra-curricular school and community volunteer activities in which you have participated to a significant degree during your time in high school. Please list items in only one category below. Do not include classes.
AWARDS AND HONORS: (Academic awards, sports awards, club awards, etc.)
AWARD/ HONOR
Check Year(s) Awarded
9th
10th
11th
12th
SCHOOL INVOLVEMENT: (Student government, sports, clubs, etc.)
GROUP/TEAM
Check Year(s) Awarded
9th
10th
11th
12th
COMMUNITY SERVICE GROUPS: (National Honor Society, church groups, 4-H, scouts, etc.)
ORGANIZATION/CLUB
Check Year(s) Awarded
9th
10th
11th
12th
PERSONAL STATEMENT: (Maximum one typed page) Attach a personal statement that will give the Selection Committee insight into you as an individual. Include qualities related to your achievements, character and potential that would make your selection as a scholarship recipient a worthwhile investment.
SPECIAL CIRCUMSTANCES (if applicable): Describe any personal circumstances you feel warrant special attention by the committee.
DECLARATION OF NEED: On a separate sheet of paper, provide the selection committee with information about your need for financial assistance to attend college.
REFERENCES: List the name, title, address and telephone number of two personal references. At least one should be a former teacher, counselor, coach or instructor. Family members and relatives may not be used.
1.
Name
Title
Telephone
Address
City
State
Zip
2.
Name
Title
Telephone
Address
City
State
Zip
CERTIFICATION: I certify that the information provided in this application is complete and accurate to the best of my knowledge. Falsification of information will exclude me from scholarship consideration.
