COMMON LOCAL SCHOLARSHIP APPLICATION

INFORMATION/ESSAY PAGE

Answer the following questions using a word processing program. Write in complete sentences. You may use two pages, if necessary, to answer all of the questions.

Name of the scholarship you are applying for:

1) Name, home address, and telephone number:

2)Age:

3)Cumulative GPA:

4)High school attended:

5)What college do you plan on attending next year (or what colleges are you considering)?

6)Write a paragraph explaining your proposed field of study and what you have done to prepare yourself for that program.

7)List anticipated college expenses with amounts. Explain how you plan to contribute toward your college expenses, including savings amounts:

8)What special circumstances should the scholarship committee know about?

9)What other scholarships have you applied for or do you plan to apply for?

10)How many family members will be attending college next year?

RESUME OF ACTIVITIES

You may use multiple pages, but list each activity only once.
School Activities:

ACTIVITYYEARS OFOFFICES, AWARDS
PARTICIPATION

Community Activities:
ACTIVITYYEARS OF OFFICES, AWARDS
PARTICIPATION

Work:
EMPLOYERDATES OFJOB DUTIES
EMPLOYMENT

Honors and awards not listed above:
AWARD DATES RECEIVED

FINACIAL INFORMATION

For this page, please print or write neatly in ink.

1)Parent name(s)

2)Marital status: ______Married; ______Separated; _____Divorced; _____Widowed; _____Single

3)Parent(s) income, expenses, and asset date for last year:

  1. Adjusted gross income: …………………………………………………………...$ ______
  2. Untaxed income and benefits (Social Security, AFDC, ADC, etc.):$ ______
  3. Medical/Dental expenses not paid by insurance: ……………………..$ ______
  4. Value of savings, bonds, stocks, CDs, notes, etc.: ……………………..$ ______
  5. Total number of exemptions: ……………………………………………………$ ______

Please explain special circumstances, if any, not explained by the applicant on page 1.

______

I certify that all of the information on this form is true and complete to the best of my knowledge.

Father’s/Step-father’s signature: ______Date: ______

Mother’s/Step-mother’s signature: ______Date: ______