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NAME:
First, Middle, Last, Suffix Name Used
MAILING ADDRESS:
Street or PO Box, City, State, Zip Code
Date of Birth: e-mail:
Telephone: (H) (W)
Father's Name:
Father's Occupation: Highest Education Level:
Mother's Name:
Mother's Occupation: Highest Education Level:
Graduation Date: High School GPA:
High School Name and Address:
Have you taken any college classes? No Yes
If yes, where: Cumulative College GPA:
College Enrollment Date:
Expected College Completion Date:
Program/Major:
Other Post-Secondary Education (if applicable):
Number of family members currenlty in college besides yourself:
Please briefly explain your educational goals:
Are you currently employed? No Yes
If yes, please list your employment history
Employed by: Position: Dates:
Why do you deserve this scholarship?
Describe your community service, including dates:
Briefly explain your career goals:
Please list any hobbies, special interests, organizations, etc. that you may have.
Describe your community service, including dates:
Please list all other types of assistance (including federal, state, and local) scholarships or
grant funds for which you have applied or plan to apply. Please identify any which you have been awarded.
Please list any important factors that you would like to be considered when reviewing your applicaiton or worthiness for this scholarship.
Do you plan to remain in or return to Madison County upon completion of your education?
Please attach a 1 page single spaced essay in response to this question.
By my signature below, I declare that to the best of my knowledge and belief the information given here is true, correct and complete. Should I be awarded a Madison County Chamber of Commerce Scholarship, I understand that a check for standard college costs (tuition, fees, books, meal plan) will be sent to me for attendance at the college of my choice. Also, I agree to send receipts to the Chamber of Commerce documenting how I spent these funds toward my college education.
Signature: Date:
Witness Name: Signature:
Applications Must Be Postmarked By: April 30
(Recipient will be recognized at the annual Scholarship Banquet in May.)
Please return to:
Chair, Scholarship Committee
Madison County Chamber of Commerce
PO Box 1085
Mars Hill, NC 28754
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