ALBANY ROUNDTABLE

CIVIC LUNCHEON SERIES

P O . B O X 7 1 0 1 - A L B A N Y, N Y 1 2 2 2 4 - F O U N D E D 1 9 7 9
W W W.A L B A N Y R O U N D TAB L E . C O M

The Albany Roundtable is offering two One Thousand ($1,000) Dollar

Scholarships to two high school seniors who are recommended by a member in
good standing of the Albany Roundtable.
THIS APPLICATION IS TO BE SUBMITTED BY A STUDENT IN HIS/HER
SENIOR YEAR OF HIGH SCHOOL. THIS SCHOLARSHIP IS CONTINGENT
UPON ACCEPTANCE AND ATTENDANCE AT A TWO (2) OR FOUR (4) YEAR
COLLEGE OR UNIVERSITY.
DIRECTIONS: Complete this questionnaire and return to the above address with
a postmark of no later than March 20, 2015 (or email to ecrosen52@gmail.com).
Please print or type all information.
Please include the following:

A letter of recommendation by a teacher/counselor from the applicants

school, or if home schooled, from a member of the community.
An official transcript containing courses, grades and school average.
An essay of 300-500 words on the following topic:
Citizenship includes the exercise of certain personal
responsibilities, including considering the rights and interests of
others. Discuss your involvement in a civic capacity which
demonstrates your commitment to the community. This can
include religious, social and/or political activities.

Date:____________________________________________________________
Name of
Applicant:________________________________________________________
Address:_________________________________________________________
Phone:_____________________________
Email address:____________________________________________________
High School Date of Graduation:______________________________________

College to which you are applying:_____________________________________

Second choice:____________________________________________________
Major (if known):___________________________________________________
If already accepted, indicate school and date of acceptance:
________________________________________________________________
Name of
Parent:__________________________________________________________
Address:_________________________________________________________
Phone:_______________________email address:________________________
I certify that all the information on this form is true and completed to the
best of my knowledge. I have completed the application with the consent
of a parent/guardian but have not received assistance from them in writing
the essay.
Applicants
Signature:__________________________Date:_______________________
Parents
Signature:__________________________Date:_______________________
Roundtable
Sponsor:___________________________Date:_______________________