GalliaCounty Emancipation Proclamation Scholarship Application
Personal Information – Please type or print
I, / have read and understand the conditions of the Gallia County Emancipation
Proclamation Scholarship as explained in the instructions. My signature indicates a clear understanding or the conditions of this application. I fully understand any falsification or breach of the award stipulations may forfeit this award in part or in whole. The information contained herein is true and accurate to the best of my knowledge and belief.
Date / Signature
Legal name in full
(Print/Type)
Last Name / First Name / M.I.

Permanent residence

Number, Street, and Apartment Number, City, State, Zip
Name & address of your high school / Name / Number / Street
City / State / ZIP

Name & address of your college/university

Name, Number, Street
City (if studying abroad, add country) / State / ZIP
How is permanent residence established?
(At least two must apply.)
Home address for school registration
Place of registration to vote
Family’s primary residence / Home telephone / ( )
School telephone
(if different) / ( )
E-mail address
Other: / Date of birth / Age
Month/Day/Year
Field of Study in College:
Eligibility: Please check YES or NO to the following:
Are you an African-American? Yes No
Have you been a GalliaCounty resident since the beginning of your high school junior year? Yes No
Are you a high school senior who will have graduated by August 1 of this year or a current college student under the age of 25? Yes No
Are you a U.S. citizen or legal resident? Yes No
Submissions:
Have you enclosed the following?
1. High School or College transcript containing GPA, ACT, and/or SAT scores? Yes No
2. Minimum three letters of recommendations? Yes No
3. An essay? Yes No
4. Additional Information? Yes No
Signature of Parent or Guardian
(if applicant is under 18 years of age
Date
Name ______
  1. List the secondary school from which you graduated and all higher education institutions attended. Include summer, study-abroad, exchange programs (up to six).

School / Location / Dates Attended
  1. List college and high school activities (student government, sports, publications, school-sponsored community service programs, student-faculty committees, arts, music, etc.). List in descending order of significance. You will have space for eight college and four high school activities.

College Activity / Dates / Offices
High School Activity / Dates / Offices
  1. List public service and community activities (homeless services, environmental protection/conservation, advocacy activities, work with religious organizations, etc.). Do not repeat items listed previously. List in descending order of significance. You will have space to list six. # of Weeks

Activity / Role / Dates / Active

Application – 2 of 5

Name
  1. List government activities (internships with government agencies, partisan political activities, ROTC/military, municipal boards and commissions). List student government under Item 2.

Activity / Role / Dates / # of Weeks Active
  1. List part-time and full-time jobs and nongovernment internships during and since high school graduation.

Type of Work / Employer / Dates / Average # of Hours/Week
  1. List awards, scholarships, publications or special recognitions you have received. List in descending order of significance.

Application – page 3 of 5

Name / Approved for use through 08/03

Application – page 4 of 5

Name

Application – page 5 of 5