Rudolph Canzater Scholarship Application
Application Deadline: June 9, 2017 (postmark date)
(Please Type or Print)
Eligibility Requirements:
Applicant must be a resident of the Sixth Congressional District of South Carolina, and plans to attend college in the academic year of 2017-2018. Additionally, applicant must have a minimum GPA of 2.0 on a 4.0 scale, demonstrate a financial need, and be classified as an entering freshman at an institution of higher learning in the fall of 2017.
The application MUST be filled out in its entirety.
Part A: Personal Data
Last Name: / First Name: / Middle Initial: / Age:
Social Security Number: - - / Sex: M F / Date of Birth: / /
Permanent Address (Street): / Apt. #
City: / State: / Zip Code:
Alternate Mailing Address:
City: / State: / Zip Code:
Telephone Number: ( ) - / Cell Number: ( ) -
E-Mail Address: / Congressional District:
How did you hear about the program? Website Student Organization Other:
Part B: Educational Background
Name of high school currently attending:
City: / State: / Zip Code:
Expected graduation date: / GPA:
Name of College you are planning to attend in the fall of 2017:
Part C: Work Experience/Summer Internships/Community Service
Company/Organization: / Dates Employed:
Duties/Responsibilities:
City: / State: / Zip Code:
Company/Organization: / Dates Employed:
Duties/Responsibilities:
City: / State: / Zip Code:
Part D: Financial Information (Please Provide Proof of Income)-FAFSA PRINT OUT
Financial Assistance Received or Pending To Date
Scholarships and/or grants awarded or pending (please specify amounts):
Loans or other income:
Information About Your Parents- *MUST BE COMPLETED*
Father’s Name: / Occupation:
Employer: / Total Annual Salary:
Mother’s Name: / Occupation:
Employer: / Total Annual Salary:
Number of parents’ dependent children (including yourself):
Number of parents’ dependent children in college (including yourself):
Part E. Additional Information
Extracurricular Activities:
Honors and/or Special Recognitions Received:
Application Check List
Applications missing any of the required materials below will not be considered.
In one envelope, please include:
·  Completed application form
·  A copy of your official high school transcript with signature and school seal.
·  A copy of college acceptance letter
·  Essay indicating your career goals and how this scholarship will assist you with meeting those goals. (Essay must be typed and should not exceed 500 words.)
·  A recent 4x4 color photograph (please print your name on the back)
·  Proof of Income (FAFSA PRINT OUT)
Certification & Usage of Photograph Authorization
Certification
I hereby certify that all information provided in this application is true and accurate. I am aware that any misrepresentation will result in the disqualification of my application.
______
Signature of applicant Date
Photograph Usage Authorization
If selected as a scholarship recipient, I hereby authorize the James E. Clyburn Research & Scholarship Foundation and/or the Rudolph Canzater Scholarship Committee to use the enclosed photograph in any print or electronic announcements of scholarship awards.
______
Signature of applicant Date
If you have any questions, please contact Janice Marshall 803-255-0003. Completed applications and required enclosures must be postmarked by June 9, 2017, please mail to:
James E. Clyburn
Research & Scholarship Foundation
Post Office Box 12548
Columbia, SC 29211