TO: THE ROTARY CLUB OF SHREVEPORT Date to be returned: December 4th
per your advisor’s instructions
Please return this application to your financial aid office. Please print all information, or
fill in the form electronically (preferred).
Name ________________________________________________________________________
First Middle Last
No. & Street City State Zip
Telephone No.
Birthplace ___________________________ Date of Birth ____________________
Marital Status: Single___________ Married __________ Divorced _____________
If employed, your employer:
Approximate annual income (not including financial aid) $ _____________________________
If married, spouse’s name:
Spouse’s occupation: _________________ Approx. annual income of spouse $______________
Number of children and ages:
Please complete the following information concerning your parents and their employment:
FATHER: Name and Address:
First Middle Last
No. & Street City State Zip
Employed by Occupation
Approximate annual income $
MOTHER: Name and Address:
First Middle Last
No. & Street City State Zip
Employed by Occupation
Approximate annual income $
Names & ages of brothers & sisters
Number living at home
High School: __________________________________________________________________
(Date, school name, city and state)
High School grade point average ___________ High School class rank ____________
ACTIVITIES (Please include scholastic and professional societies, awards and honors, social
and scholastic extracurricular activities and athletic activities.)
College/Graduate School presently attending: ______
What is your major? _______________________ Projected graduation date
Current grade point average _________________ Current class rank
Please attach a transcript covering all semesters since entering college/graduate school.
Colleges previously attended:
Do you plan to pursue further studies? If so, what field?
What are your career goals/interests?
(Please summarize your college activities, including extracurricular, athletic, & community
activities, & participation in scholastic and professional societies use extra sheet if necessary.)
Dates Name and Address of Employer Job Description
REMARKS (these questions must be answered; use an extra sheet if necessary)
1) The motto of Rotary International is Service Above Self.” What does this phrase mean to
2) Please include any remarks of a personal nature that would assist the Scholarship Committee
in its selection process.
OTHER FINANCIAL AID - Are you presently receiving financial aid of any kind?
Yes No If so, explain, including the amount received as loans or scholarships:
ADDDITIONAL INSTRUCTIONS - Please submit with this Application a statement from at
least one but not more than two current instructors, on college stationery. Statements can be
very general in nature but should provide the Committee with some insight on your study habits,
grades, class participation and work ethic.
Please return this form to your financial aid advisor according to the due date given to you by
your advisor. Late applications may not be considered. Any questions concerning the
application or selection process should be directed to your financial aid advisor.
If additional space is needed to fully answer any question, you may attach a supplement.
Submit Application