SCHOLARSHIP APPLICATION All information should written in black ink and be legible "*" indicates required fields Applicant’s Personal informationLast Name* First Name* Middle Name Date of Birth* MM slash DD slash YYYY Home Address Street Address City State / Province / Region ZIP / Postal Code Telephone Number*Home cellFamily InformationFather/Guardian’s Full Name* Occupation* Mother/Guardian’s Full Name* Occupation* EducationName of High School Attending* Address Street Address City State / Province / Region ZIP / Postal Code CodeTelephone Number of SchoolName of Guidance Counselor Telephone Number of Guidance CounselorEmail Address of Guidance Counselor Expected Graduation Date MM slash DD slash YYYY Cumulative on GPA on 4.0 Scale (unweighted) List and describe any honors, awards, and activities you have achieved:Name and location of college/university you plan to attend: Desired Major: Have you been accepted? Yes No Date of Acceptance MM slash DD slash YYYY ReferencesPlease list two people (non-relatives) who have knowledge of your character, accomplishments, and potential. Please provide their complete addresses and telephone numbers.Name Occupation Address Street Address City State / Province / Region ZIP / Postal Code Telephone NumbersHome CellRelationship to you Name Occupation Address Street Address City State / Province / Region ZIP / Postal Code Telephone NumbersHome CellRelationship to you The Committee will review and notify you of their decision. Signing below will be verification that all information you submitted is true.Applicant’s SignatureMax. file size: 64 MB.Date MM slash DD slash YYYY Printed Name Signature of Parent/Guardian if applicant is under the age of 18Max. file size: 64 MB.Date MM slash DD slash YYYY
