Fill - Free fillable THE SULLIVAN COUNTY SCHOLARSHIP FUND (C&N) PDF form

THE SULLIVAN COUNTY SCHOLARSHIP FUND

created by Alton Taylor

Completed application and all supporting documentation must be returned to:

• Your Guidance Office by Friday, April 26

th

, 2019 or

• Citizens & Northern Bank by Monday, April 29

th

, 2019

Please type or print in ink

PERSONAL DATA

NAME: _____________________________________________________________

ADDRESS: ___________________________________________________________

CITY: _____________________ STATE: _______________ ZIP: _______________

TELEPHONE: Home: ____________________ Cell: _________________________

DATE OF BIRTH: __________ EMAIL ADDRESS: ____________________________

FATHER’S NAME: _______________________Cell: _________________________

OCCUPATION: _______________________ EMPLOYER: _____________________

MOTHER’S NAME:_______________________ Cell: _________________________

OCCUPATION: _______________________ EMPLOYER: _____________________

PARENT(S) EMAIL:_____________________________________________________

NUMBER OF BROTHERS AND SISTERS: __________________________________

Are any of them attending college? __________ If yes how many?________________

If so, indicate where they are attending:_____________________________________

_____________________________________________________________________

Do you live with: Both Parents: ____ Mother: ____ Father: ____ Other:_____________

If someone other than your parents supports you, please indicate:

NAME: ________________________ RELATIONSHIP: ________________________

ADDRESS: ___________________________________________________________

CITY: ____________________ STATE: _______________ ZIP: ________________

OCCUPATION: ______________________ EMPLOYER: ______________________

Name: _____________________

Please attach additional sheets if needed for activities, keeping the same format

EMPLOYMENT (During high school years only)

Employer Type of Work No. of Hours Dates of employment

Per Week From: To:

Example: John Doe Restaurant Wait staff 10 07/01/17 to 02/15/17

_______________________ ______________ _________ ____________________

Do you plan to work part time during the college year? __________________________

Do you plan to work during the summer? ____________________________________

COMMUNITY & VOLUNTEER ACTIVITIES (During high school years only)

Organization Name Type of Activity No. of Hours Dates of Involvement

Per Week From: To:

Example: Big Brothers/Big Sisters Mentoring 3 10/01/17 to present

________________________ _____________ _________ ____________________

Indicate what types of activities you plan to participate in while attending college, if any?

______________________________________________________________________

SCHOOL ACTIVITIES (During high school years only)

Organization/Sport Type of Activity No. Hours Weeks Number of

Per Week Per Year: Years::

Example: Student Government leadership 4 36 2

_________________________ _______________ _________ _________ _______

Will you be involved in any school activities while attending college? ______________

If yes, what types of activities? ____________________________________________

______________________________________________________________________

Name: _____________________

COLLEGE AND CAREER GOALS

What major will you pursue? ______________________________________________

What degree do you expect to receive? _____________________________________

What are your plans after receiving your degree? ______________________________

_____________________________________________________________________

COLLEGE COSTS FOR YOUR FRESHMAN YEAR (Do not include personal

expenses)

Name of college you plan to attend: ________________________________________

Tuition and Fees: ______________________________________________________

Room and Board: ______________________________________________________

Books and Supplies: ____________________________________________________

First alternate college you plan to attend: ____________________________________

Tuition and Fees: _______________________________________________________

Room and Board: _______________________________________________________

Books and Supplies: ____________________________________________________

Please attach a copy of tuition/cost page from the above referenced schools, your

stude

nt financial aid package and any acceptance letters you have received.

Total Cost: __________________________________________________________________

Total Cost: ____________________________________________________________

Name: _____________________

FINANCIAL INFORMATION

To be considered for this Scholarship it is required that you supply the following

information:

Adjusted Gross Income (AGI) (parents filing separately should list each parents’ AGI):

Parents: __________________________________________

Student: ___________________________________________

Expected Family Contribution (EFC) from your Free Application for Federal Student Aid

(FAFSA). You are required to attach the first page of your FAFSA Electronic

Student Aid Report (SAR) showing your EFC ("Viewing your processed information"

upon logging into your FAFSA account will take you to the SAR.)

EFC: _______________________

List any unusual expenses or circumstances your parent or guardian has: ___________

______________________________________________________________________

EDUCATIONAL INFORMATION

GPA ______________

Please attach a copy of your official high school transcript.

REFERENCES

Please attach to this application a total of two letters of reference, from people who are

not related to you.

The first letter must be from a non-school related individual. We suggest employers,

business people, and organization leaders.

The second letter must be from a teacher, coach, activity leader, or a member of the

administrative staff from the school you currently attend or have formerly attended.

School Personnel should use the “School District Recommendation” form, following.

Name: _____________________

The Sullivan County Scholarship Fund

Created by Alton Taylor

  

School District Recommendation

Applicants: Recommendation to be completed by a teacher, coach, advisor or administrator

School District Personnel: please rate the personal qualities of this student as; outstanding,

above average, average, or below average. A written recommendation is also required. Please

use the space below and attach a separate sheet if necessary.

School District Personnel’s written recommendation:

______________________________________________________________________________

School District: ________________________________________________________________

Position: ____________________________________________________________________

School District Personnel’s printed name: ___________________________________________

School District Personnel’s signature: _____________________________________________

(Signature) (Date)

Quality

Outstanding

Above

Average

Below

Average

Cooperativeness

Respect

Initiative/work ethic

Leadership

Personal Conduct

Trustworthiness

Maturity

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signature

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Name: _____________________

ONLY COMPLETED APPLICATIONS ACCOMPANIED BY ALL REQUIRED

SUPPORTING DOCUMENTATION RECEIVED BY THE DEADLINE WILL BE

CONSIDERED FOR THIS SCHOLARSHIP.

Citizens & Northern Bank

Trust and Financial Management Group

1827 Elmira St

Sayre PA 18840

1-888-760-8192

Completed Applications will include:

____ Signed and dated Application

____ Any Applicable Acceptance Letters

____ FAFSA with Estimated Family Contribution

____ Official Transcript

____ TWO Letters of Reference

One from member of the community

One from school district (“School District Recommendation” form)

Date

Applicant’s Signature

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signature

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