THE JOHN E. TREMBLY FOUNDATION

SCHOLARSHIP APPLICATION

(Please Type or Print)Date:______

A. PERSONAL INFORMATION

1. Name______

Last First Middle Initial

2. Home Address ______

______Phone______

3. School Address ______

______Phone______

4. Date of Birth ______

5. Social Security # ______

B. MARRIED STUDENT INFORMATION

1. Spouse’s Name ______

  1. Spouse’s Address (If different from yours) ______
  1. Will spouse be a student______If so, where______
  1. If spouse is not a student, list occupation ______
  1. Do you have any dependents______If so, how many______

C. PARENT INFORMATION

  1. Father, Stepfather

a. Name ______

b. Address______Phone______

c. Occupation ______

d. Employer ______

2. Mother, Stepmother

a. Name ______

b. Address______Phone______

c. Occupation ______

d. Employer ______

D. ACADEMIC INFORMATION

  1. School Presently Attending

a. Name ______

b. Address ______

  1. Date of high school graduation ______
  1. High School from which you graduated ______
  1. Rank in high school graduating class ______
  1. High School grade point average ______
  1. ACT Scores: Reading ______Science Reasoning ______

English ______Math ______Composite ______

  1. College grade point average ______

8. Total number of college credits earned to date ______

  1. Major course of study ______
  1. List high school and college scholastic honors ______

______

______

______

E. GENERAL INFORMATION

1. Are you a resident of Morris County, KS ______

2. Are you a native of Morris County, KS ______

3. List school and community activities in which you have participated

(Please explain extent of involvement, including leadership roles taken)

______

______

  1. List work experiences, including kind of work, employer, and

approximate dates ______

______

______

  1. List other scholarships or financial aid received ______

______

  1. Comment on the interest, talent or activity that you think has

contributed the most to your development ______

______

  1. Provide the name and address of three persons, not related to you,

who might provide additional information aout your scholastic abilities,

character, leadership ability, personality and citizenship. Include at

least one teacher.

Name ______Address ______

Name ______Address ______

Name ______Address ______

  1. Provide any information not specifically requested which you feel

needs to be considered in support of your application (unusual funancial conditions, etc.): ______

______

  1. What school do you intend to attend if you receive this scholarship

______

  1. Will this scholarship affect whether you will be able to attend school

______

Please explain ______

______

  1. Is this a first time or renewal application ______

F. FINANCIAL INFORMATION

1. Father/Stepfather’s estimated annual income ______

2. Mother/Stepmother’s estimated annual income ______

  1. Please attach copies of Parents’ Federal Income Tax Returns for the

last three years. This information is required for full consideration of

this application.

G. AUTHORIZATION

We certify that to the best of our knowledge, the information contained in this application is correct and complete. We agree that the Trustees of the Nystrom Foundation have our permaission to verify this information, as well as the student’s enrollment and class attendance.

H. SIGNATURES

______

Applicant-Signature Date Signed

______

Parent Date Signed