APPLICANT DATA

NAME:
Last: First: Middle Initial:

PERMANENT HOME MAILING ADDRESS:
Number: Street: Apartment #:
City: State: Zip Code:
Phone:

DATE OF BIRTH:
Month: Day: Year: Social Security Number:

Please indicate your status (For statistical purposes only):
Male Alaskan Native American Indian Asian or Pacific Islander or East Indian
Female African American Hispanic or Latino White

EMPLOYEE PARENT OR GUARDIAN INFORMATION

Last: First: Middle Initial:
Member Company Name:
Address: City: State:
Work Telephone: Social Security Number:
Relationship to Applicant:
The applicant is a dependent of the employee Yes No

School Name:
Graduation Date: Month Year
City: State: Phone:

POST-SECONDARY SCHOOL DATA

Name of post-secondary school you plan to attend. (If unknown, please list order of preference the schools to which you have applied.) Use official school names. Do NOT use abbreviations.

City: State:
City: State:
4 yr. College or University
Other, explain
Major or course of study
Anticipated date of graduation: Month Year

WORK EXPERIENCE

Describe your work experience during the past four years (e.g., food server, babysitting, lawn mowing, office work). Indicate dates of employment for each job and appropriate number of hours worked each week. List amounts earned at each job.

ACTIVITIES, AWARDS AND HONORS

List all school activities in which you have participated during the past four years (e.g., student government, music, sports, etc.). List all community activities in which you have participated without pay during the past four years (e.g., Boy/Girl Scouts, hospital volunteer, Special Olympics). Note all special awards, honors and offices held.

GOALS AND ASPIRATIONS

Make a statement of your plans as they relate to your educational and career objectives and long term goals.

UNUSUAL CIRCUMSTANCES

Please describe how and when any unusual family or personal circumstances have affected your achievement in school, work experience, or your participation in school and community activities.

APPLICANT APPRAISAL (REQUIRED)

To be completed by a high school or college counselor or advisor, an instructor, or a work supervisor who knows you well. You have been asked to provide information in support of this application. Please give immediate and serious attention to the following statements. When complete, please return to applicant. If you prefer, photocopy this section and return to applicant in a sealed envelope.

The applicant's choice of a post-secondary educational program is	extremely appropriate	very appropriate	moderately appropriate	inappropriate
The applicant's achievements reflect his/her ability	extremely well	very well	moderately well	not well
The applicant's ability to set realistic and attainable goals is	excellent	good	fair	poor
The quality of the applicant's commitment to school and/or community is	excellent	good	fair	poor
The applicant is able to seek, find, and use learning resources	extremely well	very well	moderately well	not well
The applicant demonstrates curiosity and initiative	extremely well	very well	moderately well	not well
The applicant demonstrates good problem-solving skills, follows through, and completes tasks	extremely well	very well	moderately well	not well
The applicant's respect for self and others is	excellent	good	fair	poor

Comments ___________________________________________________________________________________________

____________________________________________________________________________________________________

Appraiser's Name ______________________________________ Title ___________________________________________

Telephone _(______)__________________ Organization ______________________________________________________

Signature ___________________________________________________________ Date ____________________________

TRANSCRIPT INFORMATION

All applicants must include a high school transcript of grades and have the following section completed by the appropriate school official. (A clear explanation of the school's grading scale must also be submitted.)

Applicant ranks ________________ in a class of _________________

Cumulative unweighted grade point average _______________/4.0 scale
Cumulative weighted grade point average _________________/4.0 scale

PSAT Verbal _______ Math _______ SAT Verbal _______ Math _______ ACT English _______ Math _______

School
Official's Signature _________________________________________________ Date ____________________________

Title _________________________________________ Telephone _(______)____________________

School Official's
Address Street _____________________________________________________________________________

City ____________________________ State ______________________ Zip ____________________

APPLICATION CHECKLIST

This application for a scholarship becomes complete and valid only when you have returned all of the following materials: