Scholarship Volunteer Services Moak

Volunteer Services Rev. J. E. Moak Memorial Scholarship
Scholarship Criteria/ Eligibility Guidelines:
- Applicant must submit at least 2 letters of reference selected from a teacher, counselor, employer, supervisor or clergy.
- Applicant must write a profile of herself/himself, stressing factors relevant to your occupational choice and professional goal(s). Qualifications you feel you have to pursue your education for your chosen profession must be in a Medical Field.
- An official high school and/or college transcript and available scores from aptitude and achievement tests.
- Applicant must submit a letter from a Medical Facility on the total number of hours volunteered.
Name*

First NameLast Name
Date of Birth *

MonthDayYear
Date
Last 4 Digits of Social Security Number *
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Name of High School*
High School Grade Point Average *
Name of College/University that you plan to attend*
Quarter/Semester Enrolled *
Will you attend Full or Part-Time?*
If part-time, what else will you be doing?
Major/Course of Study *
Expected Date of Graduation from College *
Father's Name

First NameLast Name
Father's Place of Employment
Father's Occupation and approximate income
Mother's Name

First NameLast Name
Mother's Place of Employment
Mother's Occupation and approximate income
Names and ages of Siblings
How many of your siblings are in school? blanks
How many of your siblings are in college? blank
I declare that the information reported is true, correct and complete.
Signature*

Clear
Date*

MonthDayYear
Date
It is agreed that:
- The decision of the Scholarship Committee's award is final
- Further personal and/or financial information will be provided to the committee if requested.
- Scholarship funding will be used to defray cost of tuition.
- The scholarship check will be sent directly to the college or university after the Scholarship Committee has written proof of enrollment.
I have read and clearly understand the above agreement.
Date*

MonthDayYear
Date
Parent/Guardian Name *

First NameLast Name
Should be Empty:

Volunteer Services Rev. J. E. Moak Memorial Scholarship