NEW ENGLAND CLAIM EXECUTIVES’ ASSOCIATION
SCHOLARSHIP APPLICATION
NAME: Phone:
SOCIAL SECURITY NUMBER: ______
ADDRESS: D/O/B
N.E.C.E.A. MEMBER Relationship
MEMBER’S PHONE: ______
MEMBER’S EMAIL ADDRESS: ______
List Scholarships or Financial Aid (including Athletic or College Awards), which you’ve received to date:
AID/AWARD AMOUNT YEAR
______
______
______
______
Name of College you attend (indicate entry year) or to which you’ve been accepted:
______
Course of study you plan to pursue: ______
Entry level (i.e. freshman, sophomore, etc.)______
Estimate annual costs:
Tuition______Room & Board______Books/Fees ______
STUDENT QUESTIONNAIRE
Please make your responses as complete and accurate as possible.
1. Name of High School/College______
Year of Graduation______
2. Extra Curricular Activities
School Paper______9 10 11 12 College______
Student Senate/Govt.______9 10 11 12 College______
Year Book______9 10 11 12 College______
Class Office______9 10 11 12 College______
Clubs______9 10 11 12 College______
Clubs______9 10 11 12 College______
Marching Band______9 10 11 12 College______
Orchestra______9 10 11 12 College______
Chorus______9 10 11 12 College______
Theater______9 10 11 12 College______
Senior Play______9 10 11 12 College______
Other______9 10 11 12 College______
Other______9 10 11 12 College______
3. Athletics
Soccer 9 10 11 12 ______Softball 9 10 11 12 ______
Basketball 9 10 11 12 ______Tennis 9 10 11 12 ______
Baseball 9 10 11 12 ______Football 9 10 11 12 ______
Lacrosse 9 10 11 12 ______Swimming 9 10 11 12 ______
Track 9 10 11 12 ______Hockey 9 10 11 12 ______
Field Hockey 9 10 11 12 ______Cheerleading 9 10 11 12 ______
Golf 9 10 11 12 ______Volleyball 9 10 11 12 ______
Other 9 10 11 12 ______Other 9 10 11 12 ______
4. Honors – Awards
National Honor Society ______9 10 11 12 College ______
Girls State ______Boys State ______9 10 11 12 College ______
Other ______9 10 11 12 College ______
Other ______9 10 11 12 College ______
5. Volunteer Experience
Type of Activity Name of Place
______9 10 11 12
College ______
______9 10 11 12
College ______
______9 10 11 12
College ______
6. Community / Church Activities, Organizations
______9 10 11 12
College ______
______9 10 11 12
College ______
______9 10 11 12
College ______
7. Work Experiences
Type of Experience Place of Employment
______9 10 11 12
College ______
______9 10 11 12
College ______
8. Summer of Enrichment Activity (Special Programs, e.g., E.C.A.)
______9 10 11 12 College__
______9 10 11 12 College__
9. Occupational Plans
______
______
10. Essay
For high school student, write a brief essay describing your present goal in life. For college student, write a brief essay describing how your goal(s) have changed since high school and since entering college. If they haven’t changed, please expand on your goals.
I certify that, to the best of my knowledge, all statements in this application are correct. I agree to a personal interview if requested by the scholarship committee.
Applicants Signature______Date______
NECEA Member Signature______Date______
MAIL APPLICATION TO: LISA MULLEN, 64 PALMER ROAD, PLYMOUTH, MA 02360. QUESTIONS: or 508-320-1699.