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					                                                                      Applicant #         12




TO THE APPLICANT:

Please complete this application so we can determine your eligibility for receiving funds
set aside by the Hankinson-Mantador Dollars for Scholars Chapter to assist students who
plan to go on to postsecondary education.

If any questions are not applicable to your current situation, please attach an explanatory
note referring to the questions by section. If more space is required for information on
any items, you may attach additional information. Please indicate which section the
additional information is in reference to.

You are responsible for seeing that the entire application is submitted by the deadline.
The Hankinson-Mantador Dollars for Scholars Chapter reserves the right to process only
applications found to be complete as of the application deadline.

In submitting this application, I certify that the information provided is complete and
accurate to the best of my knowledge. Falsification of information may result in
termination of any scholarship granted.

I agree that if I am offered, and accept and award from Scholarship America or an
affiliated program (Dollars for Scholars), Scholarship America and its affiliate programs
may use my name, the name of my community, the name and address of my school, the
amount of the award, and the name of the postsecondary institution I will attend in press
releases, public announcements, and other fundraising or promotional materials in all
media (including the internet), to advance the non-profit objectives of Scholarship
American and its affiliated program.

Applicant’s Signature _________________________              Date     Applicant #
________________

Parent Signature _____________________________               Date
________________
(if student is under 18 years old)


APPLICANT DATA

Name ___________________________________ Social Security #________________

Permanent Address _______________________________________________________

Date of Birth ______________ Telephone ____________ E-mail __________________
                                                                                            22


Name of parent/guardian____________________________________________________

Permanent mailing address of parent/guardian __________________________________
        (if different than applicant)
                                                       ___________________________________

SCHOOL DATA

High School Attending _________________________                       Graduation Year:__________

Address ________________________________________________________________

As of today, I am planning to attend the following postsecondary school
_____________________________________________________________________

This institution is a:                   4-year College/University           Vo-Tech
                                         Community College                   Other

Address
___________________________________________________                          Applicant #
_____________

Major field of study applicant plans to pursue ___________________________________



ACADEMIC ACHIEVEMENTS

Class Rank ______________                             Number in class? _____________

ACT Score______________

List all academic achievements you have achieved in the past four years (examples may
include: GPA, courses taken (Jr and Sr Year, Advanced/College Etc), academic honors,
etc.)
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___________________________________________________________
                                                                                     32

SCHOOL & COMMUNITY

List all school activities in which you have participated during the past 4 years (e.g.
student government, music, sports, etc.). List all community activities in which you have
participated without pay during the past 4 years (e.g. Red Cross, church work, and
volunteer work). Indicate all special awards and honors.

 ACTIVITY                       # OF       OFFICES HELD           HONORS
                                YEARS




                                                                   Applicant #




WORK EXPERIENCE

Describe your work experience during the past 4 years. Indicate dates of employment in
each job and approximate number of hours worked each week.

 EMPLOYER/POSITION            RESPONSIBILITIES         DATE       DATE TO HOURS
                                AND DUTIES             FROM       (MO/YR) PER WEEK
                                                      (MO/YR)
                                                                                                   42




PLANS/GOALS
Make a statement of your plans as they relate to your educational and career objectives
and future goals. _________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

UNUSUAL CIRCUMSTANCES
Please describe if there are any unusual family or personal circumstances have affected
your achievement in school, work experience, or your participation in school and
community activities.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
__________________________________________________




APPLICANT APPRAISAL                              (THREE - 3 -REQUIRED)
To be completed by three references: one must be the current HHS High School
Principal, the other references may be a high school or college teacher, or a volunteer
supervisor, or an employer.

You have been asked to provide information in support of this application for financial aid. Please
give immediate and serious attention to the following statements. When complete, please return
to applicant or photocopy this section and return to applicant in a sealed envelope.
extremely well      * very well   * moderately      *   not well       * poor
5                   4                 3                     2             1

The applicant’s achievements reflect his/her ability.                           ________________

The quality of the applicant’s commitment to school and community is            ________________

The applicant demonstrates initiative.                                          _______________

The applicant demonstrates good problem-
solving skills, follows through, and completes tasks                            ________________

The applicant’s respect for self and others is                                  ________________
                                                                                                                  52


Comments (Do not name student)




                                                                                                     (        )
Appraiser’s Signature                 Date              Title                                         Telephone
Number

Appraiser’s Business Address (Street)                           (City)                                   (State)
(Zip)




APPLICANT APPRAISAL                              (THREE - 3 -REQUIRED)
To be completed by three references: one must be the current HHS High School
Principal, the other references may be a high school or college teacher, or a volunteer
supervisor, or an employer.

You have been asked to provide information in support of this application for financial aid. Please
give immediate and serious attention to the following statements. When complete, please return
to applicant or photocopy this section and return to applicant in a sealed envelope.
extremely well      * very well   * moderately      *      not well      * poor
5                   4                 3                        2            1

The applicant’s achievements reflect his/her ability.                             ________________

The quality of the applicant’s commitment to school and community is              ________________

The applicant demonstrates initiative.                                            _______________

The applicant demonstrates good problem-
solving skills, follows through, and completes tasks                              ________________

The applicant’s respect for self and others is                                    ________________
                                                                                                                 62


Comments (Do not name student)




                                                                                                     (       )
Appraiser’s Signature                    Date           Title                                        Telephone
Number

Appraiser’s Business Address (Street)                           (City)                                   (State)
(Zip)




APPLICANT APPRAISAL                             (THREE - 3 -REQUIRED)
To be completed by three references: one must be the current HHS High School
Principal, the other references may be a high school or college teacher, or a volunteer
supervisor, or an employer.

You have been asked to provide information in support of this application for financial aid. Please
give immediate and serious attention to the following statements. When complete, please return
to applicant or photocopy this section and return to applicant in a sealed envelope.
extremely well      * very well   * moderately     *       not well      * poor
5                   4                 3                        2            1

The applicant’s achievements reflect his/her ability.                             ________________


The quality of the applicant’s commitment to school and community is              ________________

The applicant demonstrates initiative.                                            _______________

The applicant demonstrates good problem-
solving skills, follows through, and completes tasks                              ________________
                                                                                                  72

The applicant’s respect for self and others is                    ________________

Comments (Do not name student)




                                                                                     (        )
Appraiser’s Signature                 Date       Title                                Telephone
Number

Appraiser’s Business Address (Street)                    (City)                          (State)
(Zip)

				
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