Juneteenth – Jefferson City

Scholarship Application

Part I

Name (Last, First, Middle)______Sex (Male or Female)

Date of birth______

Name of Parent or Guardian ______Phone No.______
Address (Street or PO Box) ______

City, State, Zip ______

Parent Status (Check one)  Married,  Divorced  Separated  Deceased

Number in household size (Include yourself)______

List college/school that you will attend:______

What is or will be your Major?______

List name of social or community organizations you are or have been a member of, and any office held: ______

Attach a list of extracurricular activities you have participated in and indicate any offices held.

I have carefully read and fully understand the above and the enclosed information supplied to the Juneteenth-Jefferson City Scholarship Committee. To the best of my knowledge, I attest that all of the above information is true. I am aware that any false information will automatically forfeit this application.

Signature:______Date:______

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Juneteenth – Jefferson City

Scholarship Application

Part II -- for High School applicants (if appropriate)

To be completed by the Principal or Counselor at your high school.

Student’s Name: ______

1.High school graduation date ______

2.Has the applicant shown good citizenship while attending high school? If yes, please list an example: ______

3.Applicant’s Ranked ______in class of ______

4.List composite ACT/SAT or equivalent score______

5.Please attach a copy of the applicant’s transcripts displaying grades for the seven semesters applicant has attended high school.

6.Please use the space provided below for a brief recommendation:

______

[If more space is needed, attach an additional sheet(s)]

Signature______(Principal/Counselor)

Date______

Please submit this form and requested transcripts to:

Juneteenth Scholarship Committee

PO Box 1241

Jefferson City, MO 65102

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Juneteenth – Jefferson City

Scholarship Application

Part III -- for College or Postsecondary Institution Student (if appropriate)

Student’s Name: ______

1.College or Postsecondary Institution ______

2.Cumulative grade point average ______

  1. Attach a copy of academic transcript(s)
  2. Please use the space provided below for any additional information that may be pertinent to the committee’s evaluating your application:

______

[If more space is needed, attach an additional sheet(s)]

I have carefully read and fully understand the above and the enclosed information supplied to the Juneteenth-Jefferson City Scholarship Committee. To the best of my knowledge, I attest that all of the above information is true. I am aware that any false information will automatically forfeit this application.

Signature:______Date:______

Please submit this form and requested transcript(s) to:

Juneteenth Scholarship Committee

PO Box 1241

Jefferson City, MO 65102