Application for Country Garden Club

Helen Utley Memorial Scholarship

All applications must be completed and postmarked by April1, 2017 to:

CGC Helen Utley Memorial Scholarship Committee

c/oFran Daisey

1177 Pennsylvania Ave.

Franklinville, NJ 08322

.

First name: Last name:

Date of birth: Phone number:

Mail address: Home Address:

City: State: Zip Code:

County of residence:

Email address:

High School name (College):

HS address (College)

HS/Col phone #

Principal/Dept.Chair full name: Email address:

Advisor’s full name: Email address:

Applicant Student Certification

  1. I will be a FT college student in fall of 2017:Yes No
  1. At time of application, I am currently a:
  1. I intend to receive my degree from a:(circle)2yr 4yr
  1. The highest undergraduate degree I plan to obtain is a:
  1. My major field of study will be:
  1. My minor field of study will be:
  2. Intended career field:
  1. The college I plan to attend in the next calendar year:

Experience

Do you have a part-time job?Yes No

Where?

List employer/employers:

Experience/skills in your area of study:

Goal Essay: Describe your career, educational & personal goals that you would like to achieve in the next 10 years. (Use separate attachment, 250 words maximum).

Activities

Have you been involved in any leadership activities?Yes No

Please list and dates.

Did you participate in community service activities?Yes No

Please list and the years involved.

Student statement:

Please explain why the scholarship committee should choose you as a scholarship recipient (100words maximum)

Family Information:

(Information required to verify an application.)

Father/guardianfirst name last name

Mother/guardianfirst name last name

Contact phone #

#

Academic Information

(This information is required to help score and judge application.

Collegiate students – Use HS class ranking and ACT/SAT scores.)

Rank:

Class rank (HS)

Total number of students in class

GPA:

Cumulative GPA on a 4.0 scale

(College students use College GPA)

Please enter either an ACT score or a SAT score (HS). If you have not taken the ACT or SAT or will not be taking them, please enter zero for your score.

ACT Score:

SAT Score:

Please attach a copy of your transcript.

References:

Two references are required (i.e. teacher, community service advisor, clergy, employer).

Please attach to application.

Your advisor has to approve your application.

Student Signature Date:

Advisor Signature (HS/Col) Date:

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