1.  Name:                                                           Last                                      First                                     Middle

2.  Home Address:
                                  Street                                                    City

    
             Telephone #                                         E-Mail Address

3.      M F      
     Social Security No.                                                   Date of Birth

4.  Father's or Guardian's name:

   
                          Occupation                                                  Employer

5.  Mother's or Guardian's name:

    
                           Occupation                                                 Employer

6. Name of High School:
    Grade Point Average:
    Total ACT Scores:    English    Math    Reading
    Science Reasoning: Composite Score:
    Dates tested:
    SAT Scores: Verbal Math
    Dates tested:

7. Please list any course work taken in the following areas during high school:

    Honors course work:
   
    Advanced Placement (AP) course work:
   
    College Classes:
   
 
 
8. Sholarship Preference--YOU MUST SELECT CATEGORY FOR WHICH YOU WISH
TO BE CONSIDERED:

9.  List membership and  participation in school organizations and activities 
     including positions of leadership held, if any. Please do not abbreviate club and 
     organizational names. (If extra space is needed, please use another sheet and 
     attach.)
    
 

10.  List membership and participation in community, civic and religious
     organizations and activities including positions of leadership held, if any.  Do not
     abbreviate names. (If extra space is needed, please use another sheet and attach. ) 
    
 

11. List school or civil honors, awards or recognition. (If extra space is needed, please use another sheet and attach.)
    
     

12. College or Technical School Preferences: Have you      Have you             Intended
                                                                             applied?       been accepted?:  Major?

1st. Preference:         
2nd. Preference:         
3rd. Preference:         

14.  Work Experience:

              Employer                 Phone                   Position                         Employed
                                                                                                                From         To
    

    

    

    

15.  Please describe in a brief paragraph why you feel you should be the recipient of this scholarship.   Include any unusual family circumstances. (If more space is needed, please use another sheet and attach.)
     

16. Attachments:
        (1) Two letters of recommendation
        (2) Transcript
        (3) Copies of ACT and SAT Test Scores
 

I certify that the information I have provided in this application is complete and 
accurate to the best of my knowledge.

_________________________________________        ________________________
                  Signature of Applicant                                                     Date