Dylan Jefferies Scholarship Application Form

Dylan Jeffries Annual Scholarship Application Form
Scholarship Preference-YOU MUST SELECT A CATEGORY TO BE CONSIDERED (circle)
Four Year College/University
Identify above_________________________
Two Year College
Trade/Technical/Business School
Institution Contact number_____________________________
Intended major or area of concentration______________________________________________
High School Currently Attending____________________________ County_____________________
Name:
Last
First
Middle
Address:
Street
City
State
Zip
Telephone Number _____________________ Email Address _________________________________
Social Security Number ______________________________ Date of Birth _______________________
Father's or Guardian's Name:
____________________________
Occupation _______________________________ Employer __________________________________
Mother's or Guardian's Name:____________________________
Occupation _______________________________ Employer __________________________________
Combined/total family income____________________________
Name of High School: _________________________________
Grade Point Average: _______________ (transcript must be attached).
Please list any course work taken in the following areas during high school:
Honors Course Work:
Advanced Placement (AP) Course Work:
College Classes:
Trade/Technical/Business School Classes:
List membership and participation in school organizations and activities including, positions of leadership
held, if any. Please do not abbreviate club and organizational names. (If extra space is needed, please use
another sheet and attach.) List school or civic honors, awards or recognition. (If extra space is needed, please
use another sheet and attach.)
(Continued p 2)
Work Experience:
Most Recent Employer _______________________________ Phone ________________________
Position _______________________ Employed From____________To _______________
Please describe in a brief essay (200 words or less) why you feel you should be the recipient of this
scholarship. Include any unusual family circumstances. (If more space is needed, please use another sheet
and attach.)
RETURN APPLICATIONS AND ALL SUPPORTING MATERIAL TO SUNNY CROFT COUNTRY CLUB, ATT.
SCHOLARSHIP COMMITTEE, P.O. BOX 966, Clarksburg, WV 26302-0966 Deadline for submission is April 15,
2015. Recipients will be notified by May 1, 2015. Scholarships will be awarded at the recipient’s respective school
during their award ceremonies in May prior to graduation.
Cover letter must be attached to this application for scholarship consideration.
Any false information or misrepresentation made by the applicant shall result in immediate revocation
or termination of scholarship.
I certify that the information I have provided in this application is complete and accurate to the best of my
knowledge.
Signature of Applicant
Date
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