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 ______
- Attach a copy of academic transcript(s)
- 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