Name ____________________________________________________________________ Age ____ Date of Birth ___/___/___
Address _________________________________________________________________________________ City/State _______________________________ Zip _________
Township_______________________________ Phone: ( ) -
Name of Parent(s) or Guardian: __________________________________________________________________________________________________________________
Address of Parent(s) or Guardian: (if different from above) _______________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________
Number of children in family _____ Email: _____________________________________________
Any special circumstances we should be aware of: ___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
Graduate or student of __________________________________________________________________________________________________________________________
High School Address of High School City State/Zip
Please complete the following information about the college that you are attending or plan to attend:
_____________________________________ _______________________________ ________________ ___________________________________________________
Name of School Address City State/Zip
____________________________ ___________________________________
Major if known Minor if known
To be completed by the Guidance Dept: Attach a certified copy of the student’s ACT and/or SAT
(for High School Applications) scores, a certified copy of the student’s high school
transcript showing his/her GPA and rank in class.
If this is a college student’s Attach an official transcript of the student’s college work with GPA,
application: completed credits, current class load, and relationship with school
(full-time student? Part-time student? in good standing?)
To be completed by the applicant: 1) Attach a list of all activities (both school and community)
(for ALL applicants) during your high school or college years. Please include
employment and community service activities.
2) Attach a one page essay telling us about yourself and why you believe you should
be chosen for this scholarship. (Please use one inch margins,Arial font, font size 12,
and single spaced for the essay.)
Return the completed application by April 27, 2015.