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* 1. Applicant Contact Information

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* 2. Date of Birth (Month/Day/Year)

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* 3. Parent/Guardian Contact Information (if different from Applicant's Information)

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* 4. High School Graduation

Date

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* 5. High School Contact Information

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* 6. Post-secondary School Contact Information

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* 7. Type of School

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* 8. Is the School Accredited?

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* 9. Is this an Undergraduate or Graduate Degree?

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* 10. Year of program (in coming school year)

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* 11. Student Housing

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* 12. Student Enrollment Status

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* 13. Anticipated Graduation (Post-Secondary Program)

Date

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* 14. Major Field of Study

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* 15. Please list below the names and amounts of any Grants or Scholarships that have been awarded for the coming School year (if none have been awarded skip to the next question)

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* 16. List all School Activities participated in during the last 4 years:

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* 17. Please describe (how and when) any unusual family or personal circumstances have affected your achievement in school, work, or participation in school and community activities. If none, please skip this question.

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* 18. Share a statement of your plans, as they relate to your educational and career objectives, and future goals

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* 19. I certify and give my permission for the Association to use my Scholarship "Recipient" information (and photo) to announce this applicant (if chosen) as a winner.

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* 20. I certify the information provided within this application is complete and accurate to the best of my knowledge. Note: falsification of information may result in termination of any scholarship granted.

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* 21. Applicant's Signature (Type name to eSign)

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* 22. Date Submitting

Date

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* 23. Parent/Guardian eSignature (if applicant is not parent/guardian and student is under 18 years of age)

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