Scholarship Application 2012 - DOC by 47X793M

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									                                           APPLICATION
                                                for the
                   UNDERGRADUATE AGRICULTURE SCHOLARSHIP
                                                of the
                 PEORIA COUNTY FARM BUREAU FOUNDATION, INC.


Telephone 309-686-7070                           Application Due: March 31, 2012
Requirements: Applicants must be a Peoria County resident, a U.S. citizen, and already have
been accepted to (or intends to enroll in) a four-year university or a two-year community college.
Students may utilize a Peoria County Farm Bureau Foundation scholarship ONCE.

 Please PRINT or TYPE. All questions are to be answered (use N/A if not applicable to your situation).

Full Name _________________________________________________                 Circle one: Male     Female
             Last               First            Middle

Address _______________________________________________________________                    ___________
            Street                  City                    Zip Code                           County

Telephone _______________________              Last four digits of your Social Security # __ __ __ __

Full name of Parents or Guardian ______________________________________________________

Their address, if different than yours ___________________________________________________
                                         Street                   City           Zip Code

High School last attended _____________________________ Its Phone # _____________________

School Address ______________________________________________________________________
                   Street                      City                          Zip

Name of High School Guidance Counselor ______________________________________________

Expected Graduation date __________________ OR Actual Graduation Date ________________

A copy of the complete official transcript (including names of courses, number of credits, and grades) for
your total high school educational career MUST be submitted with this application form.


________________________________________                               ______________________
        Applicant’s Signature                                                    Date


This completed application must be received on or before March 31, 2012, at:
  Peoria County Farm Bureau Foundation, Inc. ● 1716 N. University Street ● Peoria, IL 61604

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                          Agricultural Information (40 points)
Prospective Major at College (circle one):
   Ag Communications                         Animal Science/Pre-veterinarian
   Ag Economics                              Dairy Science
   Ag Education                              Forestry
   Ag Engineering/Mechanics                  Horticulture
   Agronomy (Production Science)             Plant Science (breeding /genetics)
Other (specify) _______________________________________________________________________

What are your reasons for selecting an agriculture/agricultural-related industry as a career field?
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Ag-related organization(s) and number of years a member: 4-H _______                  FFA _______
Other (specify) ___________________________      Check here □ if FFA was offered at your school.

Leadership roles in above organizations _________________________________________________
____________________________________________________________________________________

Do you live on a farm? _____ Number of years _____ Crops raised _________________________

Types of livestock ____________________________________________________________________

Work experience on a farm ____________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

Other agriculture-related experiences and ag leadership roles _______________________________
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________


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                          Academic Information (25 points)
Grade Point Average _______ out of maximum of _______.          Class Rank _____ out of ______

      ACT composite score __________ (maximum of 36)            Date taken ____________

SAT score __________________         Date taken ____________

What academic honors and/or awards have you received during high school?
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________



List Colleges and Universities to which you have applied and/or been accepted.
    (preference will be given to students attending Illinois colleges):
1. Applied ______________________________________________ Accepted (circle one)        yes   no

2. Applied ______________________________________________ Accepted (circle one)        yes   no

3. Applied ______________________________________________ Accepted (circle one)        yes   no

4. Applied ______________________________________________ Accepted (circle one)        yes   no

5. Applied ______________________________________________ Accepted (circle one)        yes   no


List ALL scholarships or other financial aid for which you have applied. Circle the number(s) of
the ones you will receive and indicate the amount(s) you will be receiving:

1.__________________________________________________           Amount $ ___________________

2. _________________________________________________           Amount $ ___________________

3. _________________________________________________           Amount $ ___________________

4. _________________________________________________           Amount $ ___________________

5. _________________________________________________           Amount $ ___________________



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                      School and Community Activities (20 points)
                      (please answer the following questions as fully as possible)


1. In what clubs, organizations, sports, or other school-sponsored activities have you participated?
     (indicate length of membership, your activities, and leadership roles, if any)
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

2. In what non-school activities/organizations have you participated?
     (indicate length of membership, your type of participation, and leadership roles, if any).
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

3. What employment have you had to date? (give name of employer, type of work, length of employ-
ment, and whether full or part time)
____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________



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                                  Future Plans (15 points)
                                (please be as specific as possible)


1. What are your career goals? ________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________


2. What vocational and/or social experiences have you had that might be relevant to your career
    goals? __________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________


3. What other information about yourself do you wish to share that might be relevant to this
    application? ____________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________




               NOTE: Final selection may require a personal interview.

                                         Revised 1/26/12


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