Applicant Information:

Name: ________________________________________ 

Social Security Number: __________________________

Address: _______________________________________

City: ___________________________________ State: _______ Zip Code: __________

Telephone: _______________________________ Email: ________________________

Name of Parent(s) or Guardian(s)_____________________________________________

High School: ___________________________ High School Telephone: ____________

Grade Point Average (through your 7th semester): _______________________________

SAT Score (Combined): ________________ ACT Score (Combined): ______________

College or University You Plan to Attend: _____________________________________

Address of College or University: ___________________________________________

College or University Telephone No. (Admissions Office): _______________________

Anticipated Major or Area of Study: _________________________________________

Have you been accepted? ___________ If no, when will you hear? __________________

List other scholarships, grants or loans you have applied for to date and amount of each:

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Essay: On a separate page, please provide a typed or neatly handwritten statement describing how you think you have been impacted by growing up in a rural community, and how you think the community can be improved. The statement should be no more than one-letter sized page and should include your signature at the bottom of the page. 

Work Experience: List your work experience over the last four years, in chronological order, with your most recent job listed first. Attach additional page if necessary.

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School Activities: List all school activities in which you participated in the last four years (i.e., Athletics, Student Government, Clubs). Attach additional page if necessary.

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Community and Volunteer Activities: List all non-paid community activities in which you have participated in the last four years (i.e., volunteer efforts, church work).
Attach additional page if necessary.

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Awards and Honors: List all awards and honors received in the last four years (including academic awards or honors). Attach additional page if necessary.

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