2018 Scholarship Application Form This isa one-time $500.00 scholarship. It will be granted tothe school of the student's choice payable in $250.00 increments. To be eligible forthe scholarship: 1) A person of any age can apply, 2) You must be a current resident of Clebume County for atleast six months, 3) Must be applying in one ofthe following educational areas: Home Economics, Medical, Teaching, or Agriculture, and 4) You must demonstrate a need for financial assistance TO BE CONSIDERED, your application MUST be postmarked no later than March 13, 2015. Selection will be made and the recipient will be notified via certified mail by May 1, 2015. 1, NAME: ast) Cis) (Middie inital) 2, ADDRESS: (Circe. 0 Box) Gy Comiyy Zip) 3. ARE YOU A CURRENT RESIDENT OF CLEBURNE COUNTY FOR AT LEAST 6 MONTHS? 4. DATE OF BIRTH: AGE. 5, SOCIAL SECURITY # 6. HOME TELEPHONE: (__} 17. MARITAL STATUS: 8, PARENTS NAMES & OCCUPATIONS: Father: Living: Yes__No, ‘Wamey (Geena) Mother: Living: Yes___No. ‘Wame) (Cecupation) Spouse Living: Yes___No. ane) (Occupation) 9, CHILDREN ANDIOR SIBLING(S) NAMES & AGES. LIST IF st HOME, in SCHOOL, or INDEPENDENT: 10, APPLICANT: Student / Working ~- WHERE WORKING: 11. NAME AND ADDRESS of High School, College, or Trade School you are now attending: 12, SCHOLASTIC AVERAGE: in High School, Ranked ___in class of _. College Average College ranked in lass of. If information not available, please explain 13. DESCRIBE WHY YOU ARE INTERESTED IN PURSUING A HIGHER EDUCATION: 14, FIELD IN WHICH YOU ARE MAJORING OR PLAN TO MAJOR: 15, OUTLINE YOUR REASONS FOR CHOOSING THIS FIELD OF STUDY: 16. CIRCLE ANNUAL FAMILY INCOME RANGE: Under $10,000 $10,000-820,000_$20,000-$30,000 $30,000-$40,000 $40,000-$50,000 $50,000 & Above17a, WHAL ULHIK SUHULARSHLPS HAVE YOU APPLIED FOR: 17». WHAT OTHER SCHOLARSHIPS HAVE BEEN AWARDED YOU & INDICATE AMOUNTS) 18, SCHOOL ACTIVITIES: LENGTH OF TIME INVOLVED: 19. COMMUNITY ACTIVITIES: LENGTH OF TIME INVOLVED 20. INTEREST AND HOBBIES: _ ‘SCHOLARSHIP TERMS: 1. The recipient must enter school no later than the fall term following the announcement ofthe scholarship. 2, The recipient must complete two semesters in one of the following four educational areas: Home Economies, Medical, Teaching, or Agriculture. Scholarship recipient's acceptance letter must be returned to CCEHC no late than June 1, 2015. |. Recipient’ fll class schedule from a post-secondary institution must be received by CCEHC no later than August 14,2015, 5. The second class schedule must be received no later than August 15,2017. Aftee August 15, 2017, the scholarship will be void andthe second $250 scholarship payment will not be issued. DATA REQUIRED >> > > You must submit, with this application, a character reference from someone other than a family member. ‘The writer should indicate inthe letter their relationship to you. > With this application, submit an official transcript of the high school and/or college or vocational- technical school which you have or are attending. > Please mail your application and all required supporting information tothe following: CCEHC Scholarship Committee clo Cooperative Extension Service 2319 Highway 110 West, Suite D Heber Springs, AR 72543 ‘This application and all required supporting information submitted to the CCEHC Scholarship Committee ‘become the property ofthe Clebume County Extension Homemakers Council and will not be retured. All application information will be kept confidential Lave personally prepared this application and believe it to be correct. Date: 20, ‘Gigaatre oF Applicant) ‘Signature of Parent or Guardian if applicant is under 18 years of age. Date: 20, (Gignature of Parent or Goardian) ‘The Cleburne County Extension Homemakers Council scholarship awards are made without regard to race, color, national origin, gender, disability, marta or veteran status, or any other legelly-protected status. ‘CCE 12/14 Chis fo ay be photocopied)