CARL A. & ISABEL J. BACKLIN MEMORIAL SCHOLARSHIP FUND
Scholarship recipients shall be residents of the Town of Burlington
or the City of Burlington, Racine County, Wisconsin
APPLICATION FOR SCHOLARSHIP
For the academic year 2017-2018 eligible candidates are to attend an accredited college or university, or nursing school in the State of Wisconsin (the foregoing not to include technical, vocational or training schools).
INSTRUCTIONS
Please fill out this application completely. Applications submitted with questions unanswered will be disqualified. Do not staple the application or any of its supporting documentation. Return completed application to:
Town Bank
400 Milwaukee Ave.
Burlington, WI 53105
Ph: (262) 248-5875
The final determination of awards will be made by the Selection Committee as stated in the trust agreement. Awards may be used for the cost of, but not limited to, books and tuition.
APPLICATION
This application should be submitted no later than April 15, 2017.
REFERENCES
Please ask two people to serve as references, using the attached forms. One should be a teacher; the other person should be someone, other than a teacher, who is familiar with your out-of school activities, work, and community involvement.
GRADES
Please request school officials to forward transcripts of your grades to the Scholarship Awards Committee, c/o Marshall & Ilsley Trust Company (see attached request form.)
A. IDENTIFICATION
Name in Full______
FIRST NAME MIDDLE NAME LAST NAME
Home Address______
STREET CITY STATE ZIP CODE
Place of Birth______Date of Birth______
Sex______Home Phone______
Email Address______
B. WORK RECORD
List below any jobs you have held, including part-time summer vacation work.
DATES EMPLOYED NAME OF EMPLOYER TYPE OF WORK RATE OF PAY
From: To:
1.______
2.______
3.______
4.______
C. EDUCATIONAL PLANS
What college or university do you expect to attend?______
______
What are your reasons for choosing this school?______
______
______
What major or degree do you plan to pursue?______
______
______
D. POST-EDUCATIONAL PLANS
What career do you plan to pursue after completing your schooling?______
______
______
______
Why have you chosen this career?______
______
______
______
In the spacebelow write briefly about your plans and ambitions for the future. (If more space is needed write on a separate sheet of paper.)
E. LIST COMMUNITY ACTIVITIES(Church organizations, scouting, hospital, etc., and extracurricular school activities that you have been involved in during the past four years.)
COMMUNITYSCHOOL
F. COST OF COLLEGE (ANNUAL)
Tuition and Fees$______
Books and Materials$______
Room and Board$______
Misc. Expenses$______
Total Expenses$______
G. HOW ARE YOU PLANNING TO MEET THESE COSTS?
STUDENT
Savings$______
Cash$______
Employment$______
PARENTS$______
OTHER RELATIVES$______
OTHER$______
TOTAL$______
H. REFERENCES
Please ask two people to serve as references using the attached forms. One of the two people should be a teacher. The other person should be someone, other than a teacher, who is familiar with your extra-curricular/community activities. List the name, address, and occupation of each of your references in the space below. For the teacher’s occupation, list subjects taught, e.g. English or Math Instructor, etc. If that person is not a classroom teacher, list title such as advisor, student counselor, high school principal, etc.
1. Teacher: ______
NAMESUBJECT
______STREET ADDRESS CITY STATE ZIP CODE
2. Non-
Teacher: ______
NAMEOCCUPATION
______STREET ADDRESS CITY STATE ZIP CODE
I. CERTIFICATION
I hereby certify that the foregoing information in this application is true and correct.
______
Date Applicant Signature
SCHOLARSHIP RECOMMENDATION
Name of Referrer______
Name of Applicant______
How long and in what capacity/ies have you known the applicant?______
______
Please comment on the academic and/or personal characteristics of the applicant. Cite specifically the candidate’s aptitude for college-level work, (if applicable) leadership ability, integrity, and any other factors which you think are pertinent. Make an effort to distinguish this student from others by noting his or her particular strengths. Please confine your comments to the space provided.
______
Date Signature
______
Occupation
SCHOLARSHIP RECOMMENDATION
Name of Referrer______
Name of Applicant______
How long and in what capacity/ies have you known the applicant?______
______
Please comment on the academic and/or personal characteristics of the applicant. Cite specifically the candidate’s aptitude for college-level work, (if applicable) leadership ability, integrity, and any other factors which you think are pertinent. Make an effort to distinguish this student from other by noting his or her particular strengths. Please confine your comments to the space provided.
______
Date Signature
______
Occupation
J. INFORMATION FROM PARENTS OR GUARDIAN
To be filled out by parent or guardian of applicant.
FATHER OF APPLICANT:
Name______Address______
Occupation______Years of service with employer______
Name of Firm______
MOTHER OF APPLICANT:
Name______Address______
Occupation______Years of service with employer______
Name of Firm______
List dependents and their ages______
______
List other children attending college next year and amount of your contribution for each of their costs.
NameCollegeClass Cost to you
______
______
______
Remarks supporting request for scholarship:
Provide the amounts of adjusted gross income and taxable income (Husband and Wife) as reflected on your most recent calendar year federal income tax return.
ADJUSTED GROSS INCOME
(Found on line 37 of Form 1040)$______
TAXABLE INCOME
(Found on line 43 of Form 1040)$______
I hereby certify that the amount listed as parent’s contribution represents the full extent of my ability to assist the applicant. I also certify that I have read this form as filled out by the applicant, and that I approve the application.
PLEASE SUBMIT A COPY OF PAGES 1 & 2, PLUS SCHEDULES C & F, IF APPLICABLE OF YOUR CURRENT YEAR’S TAX RETURNS WITH THE SCHOLARSHIP APPLICATION. FAILURE TO ATTACH THIS DOCUMENTATION WILL RESULT IN DISQUALIFICATION OF THE APPLICANT. (PLEASE BLACKOUT YOUR SOCIAL SECURITY NUMBERS FOR PRIVACY/SECURITY PURPOSES.)
______
Date Parent or Guardian Signature
______
Date Parent or Guardian Signature
CARL A. & ISABEL J. BACKLIN MEMORIAL SCHOLARSHIP FUND
GUIDANCE COUNSELOR’S OFFICE
Name of Applicant:______
Please take this page to the high school guidance department and ask that they complete and return to you to include with your application no later than the scholarship application deadline date.
1. Attach a completed grade transcript. If you are an applicant that has already graduated from high school, please provideall post high school transcripts as well. If you are not currently attending school, briefly describe what you have been doing since graduating.
2. Cumulativegrade point (7 semesters)______
3. Rank in class______of ______
1