ANDOVER LIONS CLUB
C/O Richard O’Connell 316 Webster Lake Road Franklin, NH 03235 603-934-0245
SCHOLARSHIP APPLICATION - 2013 For College Enrollment Month/Day/Year If you are currently enrolled in college please list initial date of enrollment above. 1. Applicants Name Last
2. Date of Birth
3. Home Address
4. Telephone Number 5. Health Status (Please list any explanations necessary)
If you can be claimed as a dependent on your parents, guardians, or spouses income tax return please complete number 6 with information relative to your parents, guardians or spouse.
6. Father or Guardian/Spouse Full Name:
Mother or Guardian Full Name:
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7. If you live with your parents/guardian please list the names and ages of brothers and/or sisters or other children in the home. If you live independently or with your spouse list the names of any dependent children that live with you.
Are any of the above in college or a private school? List name and school.
Are any of the above receiving scholarship aid at the present time? List name and amount.
Have any members of your family received an Andover Lions Club scholarship? If so, please specify.
8. COLLEGE, UNIVERSITY OR TECHNICAL SCHOOL INFORMATION What school have you chosen? Have you been accepted? Give complete address of school with phone number.
9. FINANCIAL INFORMATION If you can be claimed as a dependent on your parents or guardians income tax return please complete this section including parents, guardians and your income. If not please complete including your immediate family’s income. (i.e. yourself, spouse, dependent children) Family Income:
Check one box
0 – 20,000 .............. □
20,000 – 40,000 ..... □
40,000 – 60,000 ..... □
60,000 – 80,000 ..... □
80,000 – 100,000 ... □
100,000 – 125,000 . □
125,000 – 150,000 . □
150,000 – 175,000 . □
175,000 or above ... □
List the estimated expenses at this school to be paid by you or your parents/guardians? Tuition:
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Please describe the estimated plan of payment. (i.e. parents, guardians, loans, savings, work, grants, other scholarships, financial aid, etc.)
If you will be receiving other financial aid, please specify.
10. EXTRACURRICULAR AND PERSONAL ACTIVITIES Please list your principal activities and hobbies, in order of interest to you. Include any awards or honors you have received during the past three years.
GRADE LEVEL OF PARTICIPATION
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11. WORK EXPERIENCE Please list any job (including summer or part-time work) you have held during the past three years. Nature of Work
Employer & Address
Approximate Dates of Employment
12. PERSONAL STATEMENT Please describe, in your own words, some personal experience that was significant in your life. Attach additional pages if preferred.
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13. If you have any special field of study or plans for the future in mind, please describe it here.
My signature below indicates that all the information on this application is correct to the best of my/our knowledge. If this application includes income information from a source other than the applicant, all relevant individuals MUST sign this application.
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