All applications and transcripts must be postmarked no later than February 26, 2018.

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1 Application Instructions Complete sections I V. Please print clearly. Select the required essay question from Section IV and choose one other essay question listed of your choice. Answer each essay question with a minimum of 400 words. Both essays must be typed, double spaced and included with the application. At the top of each essay, include your name and the title of the essay question you have selected.. Please request a certified copy of your latest High School Transcript and have it sent by your school to the address below by the deadline. Do NOT attach your Transcript to the application. Mail application to: Syreeta Allums Memorial Scholarship Fund PO Box 298 All applications and transcripts must be postmarked no later than February 26, Winners will be notified No Later than March 30,

2 This academic and need based scholarship has been made possible by the Board of Directors, Officers and Friends dedicated to the memory of Syreeta A. Allums. I. Personal Information Last: First: Middle Initial: Home Telephone: Alternate Telephone: Cell No: Street Address: City: State: Zip Code: Confirm Date of Birth: Gender: Male Female U.S. Citizen: Yes No If you are Not a U.S. Citizen, are you a Participant of the DACA Federal Program? If your answer is YES, include a copy of your family s prior year IRS Return. YOU DO NOT HAVE TO SEND IN THE FAFSA FORM THAT IS REQUESTED BELOW. Only fill in the Annual Household Income & How many in Family information on the next Line. II. Financial Information Annual Household Income $ How many in Family: Include a copy of your Processed/Received Confirmation of your Student Aid Report (SAR) ; this is your FREE APPLICATION FOR FEDERAL STUDENT AID (FAFSA). III. Education, Extracurricular Activities, & Achievements Include Personal Resume, copy of your SAT or ACT Score Sheet and your Family processed Student Aid Report or FAFSA. High School: City: State: Telephone: ( ) GPA: Class Rank: out of SAT or ACT Score: If your school does not Rank, we are aware of this policy at your school. Just write N/A as the Class Rank. Are you graduating High School with a 2-Year Degree? YES NO 2

3 Achievements or Awards (include any scholarships received): Advanced Academic Preparation: Include Pre-AP and IB courses Current Class/ Course Schedule: Extracurricular Activities (School sponsored): Position Held: Extracurricular Activities (Non-school sponsored): Position Held: 3

4 IV. Post Graduation Information What is your desired four-year College or University, and why? City: State Selected Major: (Include a Copy of your College Acceptance Letter that you will attend in Fall 2018) Reason for selecting Major: During your college tenure, what service project(s) within the community do you aspire to be an active participant? Why? I hereby certify that the information provided in this application is true and correct. In addition, all information obtained from this application may be used only by Syreeta Allums Memorial Scholarship Fund Inc. Scholarship Committee. We will use the information you supply on this form solely to evaluate you as a candidate for various scholarships. This information will not be available to third parties or for any other purpose. Signature Print Name Date 4

5 V. Questions What University did this named scholarship person graduate? What Year did she graduate from college? VI. Reference Letters You will need to provide 3 character reference letters from reputable sources such as your counselor, a teacher, an administrator or clergy. The letters should be typed; they must be one page or longer in length and bear the signature of reference; the letters should be attached to your application. VII. Essays Essay 1: 1. Within your lifetime, how have you overcome the odds? Essay 2: Select an additional question below for your second essay. 1. In your own words, describe what success means to you. 2. Describe your most important accomplishment. Include details of how you achieved this goal and why it is most important to you. 3. In your own words, describe something about yourself that makes you unique (different from other possible applicants). 4. Describe the event, place, person, or thing that has been most influential in your life and tell how it has influenced your decision making and impacted your life. VIII. Name/Photo Release Permission Form Fill out (page 6) as listed, no picture needed at this time. 5

6 Name/Photo Release Permission Form I,, give my permission to the Syreeta Allums Scholarship Print Full Legal Name Fund Inc. (SAMSF) and/or its representatives to use my name and photographs on its websites, promotions, advertisements and/or publications. Your Date of Birth / /. I further grant permission for SAMSF and/or its representatives to use my name and photographs at its discretion. I hereby waive any right to review, inspect or approve the finished product before it may be used by SAMSF. I hereby agree to hold SAMSF and/or its representatives harmless against any claims, demands, actions, damages, or liability related to the use of my name or photograph(s) in SAMSF publications or promotions. I affirm that I have read the statements contained in the Name/Photo Release Permission Form and fully understand and agree to their content. Signature: Date: Address: City: State: Zip: Mobile Phone #: - 2 nd Phone #: - Parent Consent on Behalf of Minor Child I hereby represent that I am the [parent/guardian] of the person aforementioned, a minor. I affirm that I have read the statements contained in the Name/Photo Release Permission Form and fully understand and agree to their content on my child s behalf. Print Name of Parent/Guardian Date: - Signature of Parent/Guardian Phone # 6

7 Leave No spaces Blank or leave out any necessary documents in your mailed application. Application Check List 1. Sections I-IV - Personal Scholarship Application completed and signed by you. 2. Include your resume. - Include a Copy of your College Acceptance Letter. 3. Section V - Questions Completed. 4. Section VI - Three Reference Letters Enclosed. 5. Section VII - Two Completed Essays. 6. Section VIII - Name/Photo Release Permission Form. 7. Official Sealed High School Transcript (mailed by your school). 8. Include Processed Student Aid Report of FAFSA. - Include Processed SAR/FAFSA completed after Oct 1, Include a Copy of your ACT or SAT scores. IMPORTANT IF ALL THE ABOVE INFORMATION IS NOT MAILED BY THE POSTMARKED DATE, YOUR APPLICATION WILL NOT BE CONSIDERED FOR THIS SCHOLARSHIP. 7