Scholarship Application

Deadline: March 31st

Janice M. Scott Memorial Scholarship Fund

You are to submit all documentation to The Janice M. Scott Memorial Scholarship Fund, ATTN: Mr. Abraham Scott, ost !""ice #o$ 1%&3, Sprin'"ield, (ir'inia &&1)1
*, ha+e read and understand the re,uirements o" the Janice M. Scott Scholarship Fund application submission process. * authori-e school personnel o" m. hi'h school to release transcripts o" m. academic record and other in"ormation re,uested "or consideration b. the Janice M. Scott Memorial Scholarship Fund Scholarship Selection /ommittee. * understand that this application 0ill be made a+ailable onl. to ,uali"ied indi+iduals 0ho need to see it in the course o" their duties. * 0ai+e the ri'ht to access an. sealed prepared and1or 0ritten documents in support o" m. application submission process. *" selected "or a scholarship, * a'ree to allo0 m. photo and mini2#*! be posted on the Janice M. Scott Memorial Scholarship Fund3s 0ebsite. * also a""irm the in"ormation contained herein is true and accurate to the best o" m. 4no0led'e and belie".

Date

_________________

Signature

___________________________________________ 5

6e'al name in "ull

7 rint1T.pe8 Last Name First Name M.I.

Address o" ermanent residence Name o" .our 9i'h School Address o" 9i'h School

Number, Street, and Apartment Number

City

State

ZIP

Sch

! Name

Address

State

ZIP

A"rican American Caucasian #ispanic Asian

# me te!eph ne% & Sch $ther ! te!eph ne% &

' '

()mai! address% Date " birth

M nth,Day,-ear

C!ass *an+% Number ______ ut " a t ta! " _____ Seni rs &Chec+ ne' I am a .S citi/en Permanent resident $n a sca!e "

Age

*esident a!ien e0pecting citi/enship by the date " a1ard

Current cumu!ati2e 3PA

Number " member&s' in h useh !d::::::::::. Number " member&s' in h useh !d 1h 1i!! be attending c !!ege during the "a!! semester__________.

5 arent or 6e'al 'uardian3s si'nature is re,uired i" applicant is under 1; .ears o" a'e.

Name%

1. 6ist hi'h school acti+ities 7student 'o+ernment, sports, publications, school sponsored communit. ser+ice pro'rams, student2"acult. committees, arts, music, etc.8 6ist in descendin' order o" si'ni"icance. 9i'h School Acti+ities Dates !""ices

&. 6ist public ser+ice and communit. or ci+ic acti+ities 7homeless ser+ices, en+ironmental protection1conser+ation, ad+ocac. acti+ities, 0or4 0ith reli'ious or'ani-ations, etc8. Do not repeat items listed pre+iousl.. 6ist in descendin' order o" si'ni"icance. Acti+ities1t.pe !" 0or4 >ole1emplo.er Dates < o" =ee4s Acti+e1A+era'e number o" hours or 0ee4s

App!icati n 4 page 5 " 6

3. 6ist part2time1"ull2time ?obs, non2'o+ernment interns, and 'o+ernment acti+ities 7internships 0ith 'o+ernment

a'encies, partisan political acti+ities, >!T/, municipal boards, and commissions8. 6ist student 'o+ernment under item 1.

@. 6ist a0ards, scholarships, publications or special reco'nitions that .ou ha+e recei+ed. 6ist in descendin' order o" si'ni"icance.

App!icati n 4 page 6 " 6