WOMEN IN LONGVIEW, Inc.
P.0. Box 161
Longview, TX 75606
2012 SCHOLARSHIP APPLICATION
Women in Longview, Inc. will award a $1,000 scholarship each to three selected graduating high school senior girls. The recipients will have a strong academic background and be interested in pursuing a field of study at an accredited college, university, technical, or vocational school. Financial need, community involvement, and letters of recommendation will also be given consideration. Applicants must be U.S. Citizens.
Please complete all areas in their entirety. If something does not apply to you, mark the area “Not Applicable.” Print or type your responses and return the application with required documents, as set out in the 2012 Scholarship Application Procedure, to Women In Longview, Inc., Scholarship Committee, P.O. Box 161, Longview, TX 75606.
NAME:
______________________________________________________________DOB:___________________
MAILING
ADDRESS: _________________________________________________________________________________________________
CITY:
_____________________________________STATE: ____________ZIP: _________________
CONTACT PHONE NUMBERS: (HOME) (WORK) (CELL)_______________
□ PARENT(S) □ GUARDIAN(S)
NAME:
_____________________________________________RELATIONSHIP:__________________________
ADDRESS
(if different than above):
_______________________________________________________________
PLACE OF
EMPLOYMENT:
____________________________________________________________________
NAME:
_________________________________________RELATIONSHIP:
_____________________________
ADDRESS
(if different than above):
_______________________________________________________________
PLACE OF
EMPLOYMENT: _________________________________________________________
COLLEGE/SCHOOL
YOU PLAN TO ATTEND: ____________________________________________________
MAJOR
FIELD OF STUDY:
_____________________________________________________________________
ACT
SCORES: English _______ Math _______ SS ______ NS ______ Composite ______________
SAT SCORES: Verbal Math _______ Total
________ HIGH SCHOOL GPA ____
SENIOR
CLASS RANK _____________ NO. OF STUDENTS IN SENIOR CLASS ______
COLLEGE
CREDITS EARNED: ______________
Page 1
Name:
__________________________
USE SEPARATE
SHEET OF PAPER WHERE NEEDED, MARKING THE SUBJECT “SEE ATTACHED”
LIST HIGH SCHOOL ACTIVITIES IN WHICH YOU HAVE BEEN INVOLVED (Include
office or title held):
LIST
HONORS OR SPECIAL RECOGNITION YOU HAVE RECEIVED:
LIST
COMMUNITY SERVICE ACTIVITIES IN WHICH YOU HAVE BEEN INVOLVED:
INDICATE
FINANCIAL CONSIDERATIONS / HOW YOUR EDUCATION WILL BE FUNDED:
(This
could include the number of children or family members that are supported
within your household.)
LIST
EMPLOYMENT I WORK EXPERIENCE:
CERTIFICATION:
I certify
that all information in my application packet is correct to the best of my
knowledge.
MEDIA RELEASE:
If I am the recipient of a Women in Longview, Inc. scholarship,
you may release my name and information about me to the media. □ YES □ NO
Applicant’s Signature:
_______________________________________________Date:____________________
Page 2
Name ____________________
PERSONAL STATEMENT
In 300
words or less, describe your educational goals and objectives and who or what
has been the strongest influence in your life.