PERSONAL INFORMATION:

Full Name:

Email

Address:  

Parent/Guardian Name:

Are you presently employed? Yes No

Hours per Week

Place of Employment:

EDUCATION:

Post-secondary school you plan to attend:

Planned major or field of study:

Estimated Yearly Cost: 

Tuition Books Room & Board

ESSAY: 

Respond to the following statement."The criterion for selection of the recipient of this scholarship states that the student shall be a role model "good citizen". According to the criteria, "good citizen" shall be evaluated on the basis of (1) respect for others particularly elderly citizens, (2) respect for property especially the property of others, (3) respect for our country, state, city & community, (4) patriotism and respect for the flag of our country, the democratic process and the free-enterprise system, and (5) honesty, dependability, service, leadership, honor and integrity. In an essay of not more than 500 words, describe how you have demonstrated good citizenship as defined above and indicate why the above characteristics are essential for good citizenship.

ACTIVITIES AND HONORS:

Extracurricular activities at high school including offices held:

Civic and Community Activities:

Honors and Awards Received: