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______________________________