Fillable Massachusetts Elks Scholarship, Inc. Major Project

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Massachusetts Elks Scholarship, Inc. Major Project

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Massachusetts Elks Scholarship, Inc.
Major Project
Application for Scholarship Assistance
Name of Applicant _____________________________________________ FOR OFFICE USE ONLY
First Middle Last District______________
Address _______________________________________________________ Lodge ______________
Street City/Town Zip Code
Telephone Number _________________ College ID No. _________________
Age, Date & Place of Birth: ________________________________________________________
E-mail address (where student can be reached) _________________________________________
Name of Father or Guardian: _________________________________________________________
Employed by: ______________________________________________________________________
Name of Mother or Guardian: __________________________________________________________
Employed by: _______________________________________________________________________
Name of single parent/guardian_________________________________________________________
Employed by _______________________________ How Long _______ Title ____________________
Elk’s fraternal affiliations of parent/guardian/grandparent: ______________________________________
Name, ages, and relationships of all person’s dependent on parents’ income:
__________________________________________________________________________________
Number of dependents who will be in college: (Next September) ______________________________
Applicant’s current extracurricular activities (be specific): _____________________________________
__________________________________________________________________________________
Applicant’s current employment, including dates, hours/week, & wages: (use additional sheets if necessary):
__________________________________________________________________________________
_________________________________________________________________________________
Name and complete address of college/university at which applicant will study or is studying:
__________________________________________________________________________________
__________________________________________________________________________________
Anticipated date of college graduation: _________________________________________
RENEWAL APPLICANT YES NO
SAT/ACT Score: GPA (College) __________________
NOTE: NO REQUEST FOR ASSISTANCE WILL BE CONSIDERED UNTIL A COMPLETE
APPLICATION, INCLUDING ALL ATTACHMENTS IS ON FILE.
63 Bay State Road • Lynnfield, MA. 01940• (781) 246-5900 • Fax (781) 245-1228 • e-mail: m.esi9@verizon.net
REVISED 2021
It is the applicant’s sole responsibility to make sure that all parts of the application and all attachments are forwarded
to the LODGE FOR ENDORSEMENT NO LATER THAN JANURAY 15.
Endorsed applications will be forwarded to the Massachusetts Elks Scholarship office no later than February 15.
Applicants must carefully read the conditions of scholarship assistance as listed on the instruction sheet accompanying
this application and must comply with all instructions in order to be considered for an award.
Applicants will be judged according to their demonstration of scholarship, leadership, initiative and family financial need.
High School:______________________________ Address:________________________________________________
ATTACHMENTS
FIRST APPLICATION
1. References: attach two letters of endorsement from responsible persons not related to you who have known and
observed you well enough to evaluate your character, ability, and academic aptitudes.
2. Birth certificate: attach a copy of your birth certificate.
3. Academic records: attach your official high school or college transcript of grades for all studies completed to date.
High School applicants must arrange to have their most recent college entrance scores (SAT/ ACT only) sent directly
to the Massachusetts Elks Scholarship office. Only official high school SAT/ACT reports acceptable. (SAT Code-3501)
COLLEGE APPLICANTS MUST INCLUDE OFFICIAL EVIDENCE OF THEIR CURRENT GRADE POINT
AVERAGE.
4. Estimate of expenses: attach a statement breaking down estimated expenses, including tuition, room and board, and
other necessities, and a statement of your arrangements to meet such expenses (for example, savings, loans, parents
contributions, work/study, etc.)
5. Financial Aid Form: attach a completed copy of the Free Application for Federal Student Aid (FAFSA) form, available
from school guidance counselors or from your college.
6. Source of Income: attach a single copy or copies of parents/guardians previous years Federal Tax Return, 1040, (first
two pages) copies of current year-W2 and/or 1099’s. (If current years parents/guardians Federal Tax return are complete
previous years return is not necessary.)
7. Letter written by applicant giving reasons why they should be considered for this scholarship.
8. Letter by parent/guardian explaining the need for scholarship assistance.
RENEWAL APPLICATION
Applicants for scholarship renewal need only attach items 3,4,5,6,7 & 8. Applications must be filed, as renewals are
not automatic.
All applications and attachments submitted pursuant to a request for assistance for the Massachusetts Elks Scholarship
become the property of Massachusetts Elks Scholarship and will not be returned.
APPLICANT’S SIGNATURE
I hereby acknowledge that I have read the instructions governing grants from Massachusetts Elks Scholarship
and I agree to abide by all rules and to provide a complete application in order that my request for assistance
may be considered. Also, I understand that the age of an initial application shall be less than 23. I further
understand that no application will be accepted from a person who has reached his/her 25
th
birthday by
February 15
th
.
________________________________________________________________ _______________________
Applicant’s Signature Date
LODGE ENDORSEMENT
The applicant is responsible for obtaining endorsement of the local Lodge of Benevolent and Protective Order
of Elks in the jurisdiction in which the applicant is a resident or which the parent/guardian is a member.
Individuals living in states other than Massachusetts are eligible to file application provided they reside within
the jurisdictional area of a Massachusetts Lodge or have a parent/guardian who is a member of a
Massachusetts Lodge.
The Exalted Ruler or Secretary and Lodge Scholarship Chairman of the jurisdictional lodge must sign the
lodge Endorsement section, certifying that they have reviewed the application and will verify the accuracy of
the statements.
This application, with attached exhibits, has been reviewed and the statement verified. It is in conformity with
rules and regulation set forth by the Board of Directors of the Massachusetts Elks Scholarship Office.
_________________________________________ __________________________________________
Lodge Name and Number Exalted Ruler or Secretary
________________________________________ _____________________________________
Date Lodge Scholarship Chairman
The EXALTED RULER or his designee is responsible for the timely submission of endorsed applications to the
Massachusetts State Elks Scholarship Office.
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MASSACHUSETTS ELKS SCHOLARSHIP, INC.
MAJOR PROJECT
Massachusetts Elks Association, Inc.
63 Bay State Road * Lynnfield, MA 01940 * (781) 246-5900 * Fax (781) 245-1228 * e-mail: m.esi9@verizon.net
INSTRUCTION TO APPLICANTS
President
William J. Hopkins, III. The Massachusetts Elks Association fosters and carries on the philanthropic work of assisting
worthy young men and women to secure the advantages of an undergraduate college education
through a corporation organized under the laws of the Commonwealth of Massachusetts and
known as the Massachusetts Elks Scholarship, Inc. The program offers grants to student
Vice-President demonstrating financial need, scholarship aptitude, and good citizenship. Grants may be
Raymond A. Avezzie renewed yearly, based on continued demonstration of financial need and academic
achievement.
Treasurer Applications must be filed, as renewals are not automatic
John J. White the rules governing scholarship assistance from the Massachusetts Elks Scholarship are as
follows:
Secretary 1. Scholarship assistance shall be for the purpose of beneficiary to secure an education for
Kathleen K. Pearson secure an education for a Bachelor’s Degree in a four (4) year undergraduate college.
Directors, 2. No assistance shall be provided for the purpose of enrolling in a night school, professional
Gerald E. Bagley School, vocational school, graduate school of a university or as a part time student of
Joseph V. Balestrieri Jr. a part-time student of a college or university
David G. Charbonneau
Michael A. Delfino 3. Scholarship assistance shall be made only to students who have been endorsed by the
Jurisdictional lodge of the Benevolent and Protective Order of Elks, or the lodge of
Parent/guardian is a member.
4. Scholarship assistance who are graduates of accredited high schools shall be made on
State President to candidates
Denise O. Shurtleff
5. No distinction as to race, color, creed, or gender shall be drawn in granting of assistance.
Advisor
Michael F. Zellen P.G.E.R.
6. No request for assistance shall be considered until the applicant has provided a complete
Application, including all required supporting documentation
7. This application must be signed and dated by the Exalted Ruler or Secretary and the Lodge
Scholarship Chairman of the B.P.O. Elks Lodge in the jurisdiction to which the applicant is
A resident or of which the parent/guardian is a member.
Administrative Assistant
Linda Pratt-Webber 8. All applications must use official Massachusetts Elks Scholarship forms.
The Directors of the Massachusetts Elks Scholarship will consider the following criteria in
making scholarship awards:
• Academic Standing
• Character references and evidence of leadership and citizenship
• Demonstrated family financial need
Applicants should note the Massachusetts Elks Scholarship awards are made is students across
the state, and that every effort is made to achieve geographic balance in the offering of these
awards. Before preparing this application, students should read carefully the procedures
outlined on the reverse side of this application and follow it completely. No request for
assistance will be considered until a complete application, including all attachments, is on file.
Deadline for receipt of applications and all supporting documents to local lodge is January 15
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Completed 5 October 2021

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