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Rod Kvidahl Memorial Scholarship Application
Last Name: Click here to enter text. / First Name: Click here to enter text.Current mailing address (Street or P.O. Box): Click here to enter text.
City: Click here to enter text. / State: Click here to enter text.
Zip Code: Click here to enter text. / Phone: Click here to enter text.
Current email: Click here to enter text.
Permanent mailing address (IF different from above): Click here to enter text.
City: Click here to enter text. / State: Click here to enter text.
Zip Code: Click here to enter text. / Phone: Click here to enter text.
Permanent email: Click here to enter text.
Date of Birth: Click here to enter text.
Place of Birth (City and State): Click here to enter text.
If NOT born in Wyoming, please list number of years of residency: Click here to enter text.
Purpose of this scholarship is to support students that have a parent who is, at the time of the award, and been employed for at least 1 year at Tronox, at its facility in Sweetwater County. Applicants can also have a parent that is retired from, or died while employed by Tronox at its facility in Sweetwater County, Wyoming.
Did you graduate from aSweetwater Countyhigh school? ☐Yes ☐No
If yes, when did you graduate (month/year)? Click here to enter text.
If no, when are you expected to graduate (month/year)? Click here to enter text.
What is the name of your Sweetwater County high school? Click here to enter text.
Name of education institution that you expect to attend this coming year (Even if undecided, please name the institution you most want to attend)? Click here to enter text.
What will be your Major Field of Interest? Click here to enter text.
What is your cumulative GPA? Click here to enter text.
*** Minimum cumulative GPA of 3.0 is required. Attach your transcript to this application.
Are you currently enrolled in a post-secondary, accredited educational institution (university, community college, trade/technical school)? ☐Yes ☐No
If yes, name of the institution? Click here to enter text.
If yes, current academic standing: ☐Freshman ☐Sophomore ☐Junior ☐Senior ☐N/A
If you have been employed in the past 4 years, please list:
Supervisor’s Name / Company/Organization / Type of work / Dates / Hours/WeekIf you are applying, or attend to apply, for any other scholarships, aids, or grants, please list them:
Name of program/scholarship / Amount Requested / Date of notification (if known)List high school (or college) activities you participated in (debate, band, sports, student organizations, etc.):
Activity / Freshman, Sophomore, Junior and/or Senior YearList community activities you participated in (church, scouts, 4-H, theatre, volunteer work, etc.):
Activity / Years of participationList all honors, prizes, or special recognitions you have received with dates awarded (academic):
Honor, prize, or recognition / Dates awardedName five courses from your recent schooling which you feel have best prepared you for college and/or your chosen major, and why:
1. Click here to enter text.2. Click here to enter text.
3. Click here to enter text.
4. Click here to enter text.
5. Click here to enter text.
From your daily classroom work or your extra-curricular activities in or out of school, what were the accomplishments in which you took pride? Please explain. (This might be a research paper, a project, or an area in which you accepted special responsibility):
Click here to enter text.
Explain any unusual circumstances at school or at home that may have influenced your record in any way: Click here to enter text.
NOTE: Please submit this completed application directly to:
Dave Caplan
Tronox- Kvidahl Scholarship
P.O. Box 872
Green River, WY 82935
307-872-2273
Financial Aid Affidavit
Please provide the following information. All information will be kept confidential.
This Affidavit is REQUIRED to be signed and dated upon submission.
Annual cost of attending the college you have chosen:
Tuition / $Books and Fees / $
Room and Board / $
Transportation / $
TOTAL / $
Estimated annual dollar amount of money you will have available from savings and job earnings to apply towards the cost of your education. Include amounts that you (the student) will contribute as well as your parents, if applicable:
Savings / $Job Earnings / $
Parents Net (Combined) / $
Mother’s Name: Click here to enter text. / Mother’s Occupation: Click here to enter text.
Address: Click here to enter text. / City/State/Zip: Click here to enter text.
Phone Number (Business): Click here to enter text. / Phone Number (Home): Click here to enter text.
Father’s Name: Click here to enter text. / Father’s Occupation: Click here to enter text.
Address: Click here to enter text. / City/State/Zip: Click here to enter text.
Phone Number (Business): Click here to enter text. / Phone Number (Home): Click here to enter text.
Number of dependents claimed on your parents’ most recent tax return:
Are any of these family members attending college? ☐Yes☐No
If yes, where are they attending? Click here to enter text.
All the information above constitutes my application for this scholarship and is true and correct to the best of my knowledge and belief. If awarded this scholarship, I agree to abide by all its requirements. As the applicant, I understand that all information will be furnished to the Selection Advisory Committee, and shall be confidential.
Date: Click here to enter text.Signed:
(Signature of applicant, written in ink)
Send completed application and transcipt