Scholarship Application Form

STAR BLENDS SCHOLARSHIP APPLICATION FORM
RECIPIENTS INFORMATION
Applicant's Legal Name: *

First Name Middle Initial Last Name
Permanent Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
E-mail *
Father's Name *
Mother's Name *
Parents Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Star Blends Customer's

Customer Spouse Child Grandchild Employee
Star Blends Employee's

Spouse Child Grandchild Star Blends Employee
Name of Star Blend's Customer or Employee
COLLEGE INSTITUTION INFORMATION
Name of Institution *
Institution Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Major (or expected major) *
CURRENT SCHOOL INFORMATION
Current Student Status: *
GPA *
ACT Score (Optional)
Participation:
(Activities|Sports|Clubs,Hobbies, Honors, Family, Responsibilities, Community Involvement, Etc.)
SCHOLARSHIP MATERIALS
Essay:

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Attach up to two page essay that describes why you would be a deserving recipient of this scholarship. Essays should provide evidence of your leadership skills, scholastic achievement, extra curricular activities, motivation, and your academic and personal goals. Cancel of
Transcript:

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Attach most recent high school or college transcript Cancel of
Video Submissions

1-3 minute video describing yourself and your involvement in agriculture. Please submit videos to LSchott@Starblends.com using https://wetransfer.com or by sending it directly emailing to me - Links to google drive, drobox, etc. are all welcomed. If you have trouble please contact Labecca Schott at LSchott@StarBlends.com

Star Blends, LLC Publicity Consent Release Form
I, the undersigned, submit this Publicity Consent Release Form and grant Star Blends LLC permission to use my application information and materials for promotional purposes of the Star Blends LLC scholarship. Promotional purposes may include but are not limited to, its website, social media, Star Blends’ local media or trade publications, the below-mentioned media, or other appropriate publications as determined by Star Blends.
Applicant's Name: *

First Name Last Name
Date of Birth *

Month Day Year
Date
Home Town & State: *

Street Address

Street Address Line 2

City State / Province
Parent's Name(s): *
Name of Local Newspaper
Local Newspaper Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Name of 2nd Local Newspaper (Optional)
2nd Local Newspaper Address (Optional):

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
As a condition of participating in the Star Blends LLC scholarship program, I: Grant Star Blends LLC the irrevocable and unrestricted right to take and use and license others to take and use my name, picture, likeness, photograph, film, videotape, and/or verbal statement in all forms, all media and all manners for any editorial, informational, promotional, internet, and/or publicity purpose of Star Blends LLC. I understand that I may be identified by name, age, and/or occupation in connection with the public, private, and/or internal use of this material. Agree that Star Blends LLC owns all images and recordings it takes of me, and I waive any and all interest in the images and recordings. I release Star Blends LLC and its parent entities, affiliated companies, and all of their respective officers, directors, employees, licensees, agents, successors, and assigns from all liability for claims and demands arising from such use. Am aware that this is a release of liability and a contract between Star Blends LLC and me, and I have signed of my own free will.
Signature of Applicant: *

Clear
Parent/Guardian Signature (If applicant is under 18 years of age)

Clear
Today's Date

Month Day Year
Date
Should be Empty:

STAR BLENDS SCHOLARSHIP APPLICATION FORM

RECIPIENTS INFORMATION

COLLEGE INSTITUTION INFORMATION

CURRENT SCHOOL INFORMATION

SCHOLARSHIP MATERIALS

Video Submissions

Star Blends, LLC Publicity Consent Release Form