Application for Dixon Community Scholarship

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1 Application for Dixon Community Scholarship Scholarships in the amount of $1,000 each are available to graduates of Dixon High School each year from the Dixon Community Scholarship Fund. Half of each scholarship, when awarded, will be paid to the school in which you have enrolled for the fall semester, and the other half will be paid when you enroll for the spring semester. The scholarship money may be used at the school of your choice. Selection of scholarship winners will be by committee and will be based on community and academic accomplishments, completion of application, financial need, recommendations, and a personal interview. Two personal recommendations are required, one from a teacher of your choice and a second from a community citizen of your choice. Your completed application must be submitted only to the Dixon High School Principal or mailed to the Dixon Community Scholarship Fund; P. O. Box 1074; Dixon, Missouri 65459, in a timely fashion to meet announced deadlines. Full Name: (First) (Middle) (Last) Home Address: (Street) (City) (State) (Phone) SSN: Father s Name: Occupation: Mother s Name: Occupation: Name of School or College you plan to attend or are attending: I Certify that: 1. The information provided in this application is complete and correct to the best of my knowledge. 2. I have read and understand the rules and eligibility requirements set forth by the Scholarship Committee. Applicant s Signature: Date:

2 General Information Financial Information: Please write the figure that is your family s adjusted gross income on the family s last 1040 United States Income Tax return (Line 33): Total number of family members living at home: ; Number in High School: ; Number in College:. Special Financial Situation:_ List other scholarships or grants for which you have submitted applications and indicate the status of those applications: Name Amount Awarded Denied Undecided Essay: Please attach a one page typewritten essay explaining how you will utilize your college education and your decision of why you are seeking a scholarship from the Community Scholarship Fund. Essays will be evaluated on the basis of content, grammar and construction. List High SchoolCollege Activities and Honors: List CommunityVolunteer Activities (Dixon or College Community):

3 High School Student Performance Data Only High School Seniors need to supply this Information The following information must be supplied by the Dixon High School I. Education: 1. Attach the current transcript from the ninth grade through the first semester of senior year. 2. Applicant s current GPA: 3. Class standing: 4. Class size: 5. Number of credits earned by the end of the first semester, senior year: 6. The applicant will graduate with how many years of high school study: 7. List any unusual course of studies unique to the applicant s graduation: II. Attendance: 1. Have the school s attendance policies been a factor with the applicant completing graduation requirements? Comment only if the answer is YES with a short explanation of the circumstances and effort of the student to _ fulf 2. Days missed: Grade: 9th 10th 11th 12th III. Conduct: Answer the following questions only if it applies to the applicant 1. Number of major discipline referrals for the current school year. 2. Number of major discipline referrals that resulted in out-of-school suspension this school year. 3. You may comment on any special or unique conduct situation (within the last three years) that may merit 4. You may comment on any outstanding high school achievements achieved by the applicant that may merit _ add Results from College Aptitude Tests: The applicant has taken the following college entrance exams: Name of Test National Percentile Composite Raw Score School Signature: Title: Date:

4 College Student Information Complete only if you are a College Applicant I. EDUCATION 1. What year did you graduate from Dixon High School? 2. What year do you expect to complete your post high school degree? 3. What college are you currently attending? 4. College entrance exam scores: SAT ACT GRE 5. Please enclose your most recent official college transcript or list of grades. 6. What is your current college GPA? 7. What title of honors courses have you taken, if any? II. COLLEGE ACTIVITIES AND VOLUNTEER WORK: 1. Activity: Academic Year: Position Held: 2. Work experiencejob description: Dates Worked: 3. Special conditions or circumstances that prevent you from working or participating in activities: 4. Special awards or honors at college or in the community:

5 Dixon Community Scholarship Fund Teacher Recommendation control # To the person completing a recommendation: You have been asked to recommend an applicant for a scholarship from the Dixon Community Scholarship Fund. All information will be handled in a confidential manner by the Board of Directors of the Scholarship Fund and only Board Members will have access to your recommendation. All members of the Board are also excluded from making any recommendations in behalf of any applicant. This completed recommendation must be submitted only to the Dixon High School Principal or mailed to the Dixon Community Scholarship Fund; P. O. Box 1074; Dixon, Missouri 65459, in a timely fashion to meet announced deadlines. Two letters of recommendation are required, one from a teacher and one from a community citizen. Name of person making recommendation: Position in School: Name of Applicant: Recommendation should address the following qualities of the applicant: [Please Check] POOR FAIR AVERAGE SUPERIOR EXCELLENT NA Motivation Dependability Character Cooperation Comments:

6 Dixon Community Scholarship Fund Personal Recommendation Form control # *********************************************************************** To the person completing this recommendation form: You have been asked to recommend an applicant for a scholarship from the Dixon Community Scholarship Fund. All information on this form will be handled in a confidential manner by the Board of Directors of the Scholarship Fund and only Board Members will have access to your recommendation. All members of the Board are also excluded from making any recommendations on behalf of any applicant. This completed recommendation must be submitted only to the Dixon High School Principal or mailed to the Dixon Community Scholarship Fund; P. O. Box 1074; Dixon, Missouri 65459, in a timely fashion to meet announced deadlines. Name of person making recommendation: Position in Community: Address: Telephone: Name of Applicant: In what capacity do you know the applicant? [Please Check] POOR FAIR AVERAGE SUPERIOR EXCELLENT NA Motivation Dependability Character Cooperation Comments:

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