705 West Fair Play Street (P.O. Box 865) Bolivar, Mo 65613

705 West Fair Play Street (P.O. Box 865) Bolivar, Mo 65613

POLK COUNTY MUTUAL INSURANCE COMPANY

705 WEST FAIR PLAY STREET (P.O. BOX 865) BOLIVAR, MO 65613

1-888-70-PCMIC (72642) or (417) 326-4914

SCHOLOARSHIP PROGRAM APPLICATION

High School submits
Mr. /Ms. as an entrant for the Polk County Mutual Insurance Company Scholarship Program. The applicant will graduate this spring and plans to continue his/her education in an accredited college or university.
STUDENT’S HOME ADDRESS
City / State / Zip Code
Telephone / Parents Name
College, university or educational institution student plans to attend (name of school & address):
First Choice:
Second Choice:
I have completed this application fully, truthfully, and accurately. I wish to be considered as a candidate for the Polk County Mutual Insurance Company Scholarship.
Student’s Signature ______Date ______
Principal/ Counselor’s Signature ______Date ______
If selected, contact (school representative/ #): ______
Best time to contact: ______
Submitting Agent/ Agency (if applicable): ______

NOTE: PLEASE RETURN YOUR COMPLETED APPLICATION

TO POLK COUNTY MUTUAL INSURANCE COMPANY

OFFICE BY MARCH 1

Applicant number (PCM office use only) ______

OBJECTIVE CRITERIA LIST

POLK COUNTY MUTUAL INSURANCE COMPANY SCHOLARSHIP PROGRAM

Part I, II, and III of this form are to be completed by the applicant’s principal or counselor. Parts IV, V, VI, VII, and VIII are to be completed by the applicant: All pages must be returned to Polk County Mutual Insurance Company, and all questions must be answered. (Please type or print.)

  1. College entrance examination score (ACT or SAT)

Note: Please indicate the type of examination taken.

___ (ACT) composite score______

___ (SAT) composite score______

  1. Student’s cumulative high school grade point average (GPA)

(excluding spring semester of senior year)______

  1. Please list student’s classes for terms indicated.

Junior Year / Grade / Senior Year / Grade

PLEASE NOTE ANY HONOR CLASS

Additional notes sections I, II, & III: ______

______

The above information is an accurate description of the applicant’s grades/ scores.

Principal or Counselor Signature ______Date ______

Objective Criteria List:

  1. Financial Need – In the space provided please indicate your family’s adjusted gross incomefrom last year’s tax return.

under $25,000 $60,001 to $80,00

$25,001 to $40,000 $80,001 to $100,000

$40,001 to $60,000 over $100,000

Total number of family members living at home:

Number of dependents in your parent’s family including yourself:

Children Ages No. Attending College

Other financial considerations, which need to be noted:

  1. Extracurricular Activities – Organizations and Clubs (Show years of involvement; also please indicate any office held):

Honors and Awards

Community or Other Activates

  1. Work Activities – Are you now employed?Yes No

If yes, what type of work and how many hours per week?

Objective Criteria List:

  1. Work Activities – Continued – Describe your other work activities (such as family farm, helping at home, family business, ect.):
  1. In the space provided below, please describe in 75 words or lessand in your own words and handwriting why you want to be a recipient of the Polk County Mutual Insurance Company Scholarship, the course of study or major field of interest you plan to follow, your proposed occupation or profession, and any other abilities you have that were not previously mentioned in this form.

______

  1. Does your family or a relative have insurance coverage with Polk County Mutual Insurance Company? If so, name/ relation:
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