Personal Information

Name:

Social Security #: - -

Address 1:

Address 2:

City:

State: NC

Zip:

County:

Telephone: ( ) -

Name of Parent(s) or Guardian:

Family Size (including self & siblings):

Number in college other than yourself:

Do you receive (or do you anticipate receiving) any financial support from other scholarships or grants? yes no

If yes, indicate type of support:

Academic Information

High School from which you graduated (or will graduate):

Academic Honors:

Extra-Curricular Activities (includes school, atheletics, community, church):

Other

Describe Work Experience:

What is (or will be) your major?:

In the area below, please include a brief biographical sketch. Describe your interests, accomplishments, your future plans, and how you would benefit from the scholarship funds. Describe any special or unusual financial circumstances affecting your family.

When you press submit, this form will be compiled in your email client. If you have anything you wish to attach to the file at that time (pictures, etc) feel free to do so and send the file to us. Thanks! If you are in a library or some such location where you do not have a registered email client (ie - Outlook) the form may or may no send depending on the settings. In that case, please download the form and mail it to the listed address.