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.