Application for Local Scholarships. Please type or print in ink. Name_______________________________________________Date of Birth_______________ Address_____________________________________________Phone_____________________ Father’s Name________________________________Occupation_________________________ Mother’s Name_______________________________Occupation_________________________ List the names and ages of your brothers and sisters_____________________________________ ______________________________________________________________________________ Name and location of the school that you wish to attend__________________________________ _______________________________________________________________________________ Intended course of study or major____________________________________________________ Have you applied?_____________________Have you been accepted?_______________________ List your approximate anticipated expenses for the first year of school: Tuition_______________________ Room and Board_______________________ Books, supplies________________ Other expenses________________________ List your anticipated sources of income and approximate amount from each source (savings, part- time job, loans, etc.)_______________________________________________________________ ________________________________________________________________________________ Annual family income: Below $15,000 ___ $15,000 - $25,000 ___ $25,000 - $35,000 ___ $35,000 - $45,000 ___ $45,000 - $55,000 ___ $55,000 - $65,000 ___ Above $65,000 ___ Are you a 21st Century Scholar? Yes ___ No ___ What financial help can you expect from your parents?_____________________________________ _________________________________________________________________________________ List your employment record beginning with your most recent job: Place_______________________________________________ Date__________________ Place_______________________________________________ Date__________________ Use the space below to list extracurricular school, community, and church activities during high school (include offices held): ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ In the space below write a brief autobiography. This could include information about your career goals, your family situation, any unusual financial problems that you might have, and any other information that you feel would help in scholarship selection. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Applicant’s Signature___________________________________________________ Parent/Guardian’s Signature______________________________________________ …………………………………………………………………………………………………………… Do not write below this line Class Rank___/___ G.P.A.____/4.00 Test Scores: P.S.A.T. Verbal____ Math _____ S.A.T. Verbal____ Math_____ Counselor’s Signature______________________________