[Applicant Name], Class of 2014

(Academic Advisory Teacher: [TEACHER])

SCHOLARSHIP: Cumulative GPA: [GPA] SERVICE PROJECTS

Dates School Year 10 11: Current Semester: 9-30 to 10-1-11 [insert here] [insert here] [insert here] Name & Nature of Service [insert here] Market Day [insert here] [insert here] [insert here] No. of Hours [insert here] [insert here] [insert here] [insert here] [insert here] Reference Person Mrs. Clift Mrs. Clift Mrs. Clift Mrs. Clift Mrs. Clift Full Signature of Reference

LEADERSHIP
Dates [insert here] [insert here] [insert here] Category [insert here] [insert here] [insert here] School Activity [insert here] [insert here] [insert here] Responsibilities [insert here] [insert here] [insert here] Reference Person [insert here] [insert here] [insert here] Full Signature of Reference

CHARACTER
Teacher [insert here] Teacher [insert here] Teacher [insert here] Community Member [insert here] Extra-Curricular [insert here]

I understand that completion of this form does not guarantee membership; rather, it indicates that I am being considered for membership in the National Honor Society. I will accept the decision of the Faculty Council charged with the responsibility of selecting member as final. Student Signature Date Parent Signature Date