IMPORTANT: Before Preparing This Application, It Is Recommended That the Procedures Outlined

KENNETH BURRES

SCHOLARSHIP FUND

IMPORTANT: Before preparing this application, it is recommended that the procedures outlined

onthis page be carefully studied and then completely executed.

GENERAL INSTRUCTIONS FOR COMPLETING YOUR APPLICATION

Applications and all supporting documents must be in English or English translation.
Letters may be originals or photocopies on one side of a single sheet of 8 ½” x 11” paper signed by the author.
Official high school transcript of student’s records from the beginning of the 9th grade to due date of application may be photocopies that bear an original signature of the proper school authority.
SAT and ACT test scores, or related equivalent, must be included but may be photocopies. It is preferable that exhibits such as awards and medial items be photocopies.
All applications must be properly bound on the left side with hinges or staples in a standard binder or cover. Elaborate bindings are discouraged. Clear plastic or bulky covers are undesirable.
The application must be arranged in the order described below:
Application of Required Facts. Carefully plan a response to each item before typing in the final draft. Using 1 for the freshman year of school and numbering subsequent years 2, 3 and 4, identifying appropriate scholastic, extra-curricular and civic activities. Secure all required dates.
The applicant shall prepare a statement of 300 words or less setting forth his/her vocational or professional goal and relate how past, present and future activities make the accomplishments of this goal probable. The applicant by deed and circumstance must demonstrate his/her commitment to furthering education and/or training. The letter must be signed.
The parent/guardian shall prepare a statement of 200 words or less summarizing the family’s obligations and resources. The statement needs to illustrate the applicant’s need for financial assistance and the inability of the family to satisfy these needs. The statement must be signed.
Official signed transcript of high school grades.
College entrance test scores required (ACT or SAT or related equivalent.) Photocopies or printouts from the websites are acceptable. It is not necessary to send a separate sheet of test scores if they are included on your transcript
Proof of college registration
Any other letters/documentation in support of financial need.

PERSONAL INFORMATION

Legal Name:

Home Address:

Mailing Address:

Phone: Email Address:

County of Residence:Number of years living in county of residence:

Gender: ☐Male ☐FemaleDate of Birth: Age: Place of Birth:

Name and Address of High School:

Are you currently an American citizen? ☐Yes ☐No (Applicant MUST be a citizen on the date the application is signed.)

If not born an American citizen, please give date, place (office or court where naturalization occurred) and of Naturalization Number. If you were naturalized under the Child Citizenship Act of 2000, please include your parent(s) naturalization information:

Date: Place: Number:

ACADEMICS

List schools attended (ninth through twelfth grades):

Name of SchoolDate of EntrancePeriod Attended

Date you will graduate: _____Number of students in your class: _ __ Class Ranking: ______

Current Accumulative GPA: ______Highest ACT Score:______Date Taken:______

Highest SAT Score:______Verbal: Math: Writing: Date Taken:______

School applicant will attend next fall:

Expected degree:

ACADEMIC HONORS AND AWARDS

List Scholastic and other school related extracurricular honors and awards received during grades 9 through 12. Select the year received, state the nature of award (i.e Girl Scout Gold Award), and select the level of recognition.

Grade Level Level of Recognition

State/ Inter-

9 10 11 12 School Regional National national

☐☐☐☐ ☐ ☐ ☐ ☐

☐☐☐☐ ☐ ☒ ☐ ☐

LEADERSHIP AND EXTRACURRICULAR ACTIVITIES

List your principal leadership roles and extracurricular activities, in the order of importance to you. State the name of the organization, years involved, hours per week commitment, leadership role and responsibilities held in that role. Examples include but are not limited to student government, publications, debate, band, varsity athletics, church groups, performing arts, etc.

Organization Grade LevelHours/Week Weeks/Year Positions Held/Honors Received/ Letters Earned

9 10 11 12

☐☐☐☐

COMMUNITY SERVICE

List community service you performed from grades 9 through 12, starting with the most recent.

Specific nature of Service Organization Approximate Dates of Service Total Hours

FromTo

GRAND TOTAL HOURS OF SERVICE=

WORK EXPERIENCE

List all employment/jobs that you have held starting with the most recent and include work on a family farm, for a family business or internship even if you were not paid. List approximate total hours worked, not average hours per week.

Specific Nature of WorkEmployer Approx. Dates of Employment Total Hours

From To

GRAND TOTAL HOURS WORKED=

Total personal savings: $

PARENTAL FINANCIAL INFORMATION

Complete the financial information based on your previous years IRS 1040. If parents are divorced or separated, answer the questions for the parent the applicant lived with most in the past 12 months. If the applicant lived with both parents an equal number of days in the past 12 months, count the parent who provided the greatest amount of support, financial as well as material. Material support includes cars, clothing, medical and dental payments, etc. If that parent has remarried, the stepparent’s information must be included.

Father: Age: Occupation:

Mother: Age: Occupation:

Stepfather: Age: Occupation:

Stepmother: Age: Occupation:

Custodial parents marital status as of today:

Mother:☐Married☐Single☐Widowed☐Separated☐Divorced☐Remarried

Father:☐Married☐Single☐Widowed☐Separated☐Divorced☐Remarried

With whom does applicant make his/her permanent home? ☐Mother☐Father ☐Both ☐Other

Date of divorce or separation (if applicable):

Number of people in family, not including parents, who will receive the majority of parental support between September and August (upcoming academic school year). Include dependent children and others living in household who receive more than half of their support from the parents (e.g. dependent grandparent, etc.):

Number of dependent children including applicant attending college at least half time during current academic year:

List the name and age of siblings or other dependents. Indicate what school(s) they attend if applicable:

Name Relationship Age School/College Years Attended

Based on your previous years IRS 1040, indicate the custodial parent(s) adjusted gross income$

Did you qualify for free or reduced lunch at your school? ☐Yes ☐No ☐Not sure

Have you filled out a FAFSA? If so, please report your expected family contributions as listed on FAFSA: $

FINANCIAL NEED/OTHER SCHOLARSHIP INFORMATION

Have you been granted scholarship aid? ☐Yes ☐NoIf so, give details:

Do you intend to apply for financial aid at the college you plan to attend? ☐Yes ☐NoIf so, give details:

Have you any reason to expect scholarship aid from any other source? ☐Yes ☐NoIf so, give details:

Describe any special circumstances to show financial need such as medical conditions, disabilities, etc. that may affect your ability to pay for your college tuition. Be specific in this:

______

SIGNATURES

By signing this application, you agree, if asked, to provide information that will verify the accuracy of your completed form. If you purposely give false or misleading information, you will be disqualified from this contest.

Date:Signed by:

Student

Date:Signed by:

Mother/Stepmother/Guardian

Date:Signed by:

Father/Stepfather/Guardian

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