APPLICATION FOR SCHOLARSHIP AWARDED BY THE



APPLICATION FOR SCHOLARSHIP AWARDED BY THE

HARTSELLE SCHOLARSHIP FOUNDATION, INC.

APPLICATIONS MUST BE PRINTED OR TYPEWRITTEN.

DEADLINE FOR APPLICATION: Mail your application to the Hartselle Scholarship Foundation, Inc., 709 Celia Drive, Hartselle, Alabama 35640. Applications must be postmarked no later than April 26, 2019. You may also hand deliver your application to the Guidance Office at Hartselle High School, 1000 Bethel Road, N.E., before noon, on FRIDAY, APRIL 26, 2019. Complete your original application with all attachments. Once your application is complete make three (3) additional copies of the application WITH ATTACHMENTS. STAPLE - (DO NOT PAPERCLIP) each copy of the application and attachments together and turn in a total of 4 (the original plus three (3) copies). Put the four (4) complete sets in one envelope and mail or deliver in accordance with instructions given above. Failure to do so will void your application. Please do not put your application in binders or separate envelopes.

AT THE BEGINNING OF THE 2019-2020 SCHOOL YEAR, APPLICANT WILL BE ENROLLED AS A (Please check one of the following):

_____ Freshman _____ Sophomore _____ Junior _____ Senior

_____ Graduate School Student _____ Vocational or Technical School Student

APPLICANT GRADUATED FROM HARTSELLE HIGH SCHOOL OR MORGAN COUNTY HIGH SCHOOL IN THE YEAR __________.

APPLICANT’S NAME: ______________________________________________________

ADDRESS: _________________________________________________________________

CITY, STATE, ZIP: _________________________________________________________

(Use the address you want to be used when contacting you during the 2019-2020 school year.)

PHONE: _____________________________________________________________________

(Home) (Phone at school, if different and number is available and cell phone.)

EMAIL: _____________________________________________________________________

PLEASE SIGN THIS APPLICATION! The signature of the applicant on this form constitutes a certificate by the applicant that, to the best of his/her knowledge, the facts set forth on this application are true and correct. The applicant further certifies that he/she will promptly notify the Hartselle Scholarship Foundation, Inc., if he/she later finds the information provided herein is no longer correct. Specifically, the Hartselle Scholarship Foundation, Inc., should be notified IN WRITING if the applicant’s career plans change, if the applicant decides to attend a school other than the one reported to the foundation upon receipt of a scholarship; or if the applicant is the recipient of another scholarship. MAIL CHANGES TO: 709 Celia Drive, S.E., Hartselle, Alabama 35640.

Submitted this ____________ day of _______________________________, 2019.

__________________________________

Signature

ATTACH TO THIS APPLICATION:

1. PHOTOGRAPH: Please attach a photograph

of applicant (copies of photos are acceptable)

in space provided to the right.

2. TRANSCRIPT: Please attach a copy of applicant’s

transcript for the last two (2) years of school. (Official

transcript is not required.) Remember school offices Affix Photo Here

are closed during Spring Break.

3. TEST SCORES: Please attach a copy of applicant’s

most current and applicable test scores (i.e., for high

school graduates, ACT or SAT scores; for graduate

school applicants, GRE or GMAT scores; for medical

school applicants, MCAT score; for law school

applicant’s, LSAT score; for Pharmacy school applications,

PCAT score.

Attach to the application responses to the information requested below. Please number the responses to correspond to the numbered paragraphs.

4. SCHOOLS ATTENDED: List every school you have ever attended. Please give the grade (through grade 12) and the years you were enrolled. Also, please list the town or community of your residence while attending. If the school was a college, university or some other post-secondary institutions, please state the degree(s) earned or the semester or quarter hours earned toward a degree.

5. CURRENT ENROLLMENT: If currently enrolled in a post-secondary institution (college or trade school after high school), please list the name of the institution, your field of study (or major), the number of hours required to earn the degree you are pursuing and the number of hours you have earned towards that degree. (Please designate semester hours)

6. CHOICE OF SCHOOL: Please state the name of the school you plan to attend if you receive scholarship assistance from the Hartselle Scholarship Foundation. Also, please state the name of the school you will attend if you do not receive scholarship assistance from the Hartselle Scholarship Foundation, Inc.

7. PROJECTED COSTS: Please itemize the expenses you expect to incur for a nine (9) month school year. List the projected expenses separately. Specifically, list the following: projected tuition costs, housing cost, including utilities, if renting; meals; transportation; books; clothes; and the costs of any specialty items required such as tools or equipment, etc.

8. OTHER FINANCIAL ASSISTANCE: Please list any other scholarship(s) or awards of financial assistance you have been awarded. Include the benefactor, the amount of the scholarship or award and the school year(s) the scholarship was used or is to be used. Also, list from what other source(s) you expect to receive funding for your education (e.g., parents, spouse, your savings, government insured student loans, Pell grants, rich uncle, publisher clearing house sweepstakes, Georgia or Florida lottery, etc.)

9. ESSAY: Please state in five hundred (500) words or less why you want this scholarship. Feel free to express yourself without limitation to any subject matter. Simply put, there is no right or wrong answer to this part of the application. Some ideas or information you might want to share with the selection committee are:

a. What you intend to do with your degree or training.

b. Why you need or deserve a scholarship.

c. Why you are pursuing a college education

d. Your immediate plans and your long range goals.

e. Any extenuating circumstances concerning your family.

f. Anything else you think the selection committee might be interested in knowing.

10. EXTRA-CURRICULAR ACTIVITIES, HONORS, and ACHIEVMENTS: List your extra-curricular activities, academic achievements, honors and leadership positions held during your academic career. If you have prepared a resume, you may include the resume instead.

11. FAMILY: Please give the following information about your family. List the names and address(es) of your father and mother. List the name of your spouse and the name and ages of your child(ren), if any. Also, please list the name, school and grade or class of each sibling who is now or will likely be attending college before you complete your formal education, if any.

12. YOUR CONTRIBUTION: Please state what efforts you have made to finance your own college expenses.

13. FAMILY’S CONTRIBUTION: Please state what sacrifices or contributions, if any, your family members are making to help you with your education.

14. EMPLOYMENT HISTORY: Please list all of the places you have been employed, including current employment, if any. Include the dates of your employment and a description of your job.

15. REFERENCES: Please provide name, address and phone number of five (5) people who are personally familiar with you and will be willing to respond to inquiries from members of the scholarship selection committee regarding your character, citizenship and academic ability. If possible, at least three (3) of the five (5) references should be currently living in Hartselle, Alabama.

On the following page you will find two (2) Information Release Authorization forms. Please acknowledge these forms in the presence of a Notary Public. Have the notary affix his signature and seal to the form and return the signed forms with your application. These forms may be used to obtain information about you from any law enforcement agency, employer or former employer, or any school you are currently attending or have attended in the past.

STATE OF ____________________________

COUNTY OF __________________________

The undersigned hereby authorizes any person, teacher, administrator, school official, employer or former employer, law enforcement agency or government officer to release any information or records and give any requested information concerning my grades, activities and work habits and character to the Hartselle Scholarship Foundation, Inc.

I have applied for scholarship funds being awarded by the Hartselle Scholarship Foundation, Inc., and do hereby acknowledge that I have given my permission and consent to the release of any information you may have to the Hartselle Scholarship Foundation, Inc.

I further state that a photocopy of this release may be used as an original.

WITNESS my hand and seal this ____ day of ____________________________, 2019.

_______________________________

Signature

Sworn to and acknowledged before me this _____ day of ____________________, 2019.

_______________________________

Notary Public

Affix Notary Seal

STATE OF ____________________________

COUNTY OF __________________________

The undersigned hereby authorizes any person, teacher, administrator, school official, employer or former employer, law enforcement agency or government officer to release any information or records and give any requested information concerning my grades, activities and work habits and character to the Hartselle Scholarship Foundation, Inc.

I have applied for scholarship funds being awarded by the Hartselle Scholarship Foundation, Inc., and do hereby acknowledge that I have given my permission and consent to the release of any information you may have to the Hartselle Scholarship Foundation, Inc.

I further state that a photocopy of this release may be used as an original.

WITNESS my hand and seal this ____ day of ____________________________, 2019.

_______________________________

Signature

Sworn to and acknowledged before me this _____ day of ____________________, 2019.

_______________________________

Notary Public

Affix Notary Seal

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