John Jackson Memorial Scholarship Application
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Applicant Information
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Name:
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Date of birth:
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E-mail:
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Phone:
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Current address:
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City:
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State:
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ZIP Code:
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Do you have a job?* Yes No
(Please circle)
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Will you have to work while you are in school? Yes No
(Please circle)
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High School Information
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Awards:
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Do you know of other scholarships you will receive? Yes
No (Please
Circle)
If yes, please List below:
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1.
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2.
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3.
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4.
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Your GPA:
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Rank in Class:
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Attendance: Good Poor (Please
Circle)
Please attach signed
attendance form.
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Please circle the activities that you have been involved in during your high
school years:
After-School Assistant Teacher Baseball Basketball Beta
Club Bible Club Drama English Honor Society FCA
Football Golf Science Club Science Fair Underground
Society Yearbook Staff Others:
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Please list honors that you have won:
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ACT: SAT:
Other: Do
you plan on retaking these test(s)?
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Parent/Guardian Information
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Mother’s/Guardian’s Name:
Father’s Name:
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Address:
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Phone:
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City:
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State:
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ZIP Code:
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Combined household income: ______Less
than $10,000 _____$10,000 to
$20,000 ______ $20,000 to $30,000
______$30,000
to $40,000 _____$40,000 to $50,000
______ $50,000 to $60,000
______$60,000
to $70,000 _____$70,000 +
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Siblings in the household:
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How many siblings are currently enrolled in college or technical school?
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Do either your parents or siblings have serious medical problems?
Yes No (Please circle)
Please explain if you circled yes:
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College/Tech Information
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Preferred College/Technical School Name:
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Have you accepted? Yes No (Please
circle)
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Will you get a grant? Yes No
(Please circle)
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Anticipated major?
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How long will it take you to complete your degree?
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ANTICPATED COLLEGE/TECHNICAL SCHOOL EXPENSES
Tuition ________________________ Housing_________________________
Books____________________________
Fees__________________________ Travel/Mileage____________________
Other_____________________________
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Student Employment Information*
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Current employer:
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Employer address:
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How long?
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Phone:
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E-mail:
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Fax:
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City:
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State:
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ZIP Code:
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Position:
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Hourly Salary (Please
circle)
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Annual income:
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References (Teachers/Supervisors/Clergy)
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Name
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Address
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Phone
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Signatures
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I verify that all of the above information is correct.
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Signature of applicant:
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Date:
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Signature of parent:
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Date:
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