BASIL L - IRSC Foundation
THE ADRIAN M. SAMPLE SCHOLARSHIP TRUST RENEWAL APPLICATION Deadline to apply is Monday, May 11, 2020. Student InformationName____________________________________________________________________Last FirstAddress__________________________________________________________________City______________________________ State _______________ Zip Code________Gender______ Single____ Married____ Divorced____ Date of Birth____________E-mail Address _______________________________________________________________Cell Phone Number ( ) ______________________________________________________Religious Information Religious Affiliation: ___________________________________________________________Name of ChurchChurch Address: _______________________________________________________________StreetCity StateZipPastor’s Name: _____________________ Church Telephone (____) _______________List any church activities in which you participate:_____________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Academic InformationName of current College or University ______________________________________________College/University Student ID #_________________________________________________College/University I will attend next year_________________________________________Location________________________ Major field of interest_________________________Cumulative GPA____________ Anticipated date of Graduation_______________________Program of Study____________________________________________________________Degree Sought:_______ Bachelor’s _______ Master’s_______ Doctorate (PhD)_______ OtherCredit hours completed this semester:______12 or more (full-time)______ 9 to 11(3/4-time)______ 6 to 8 (part-time)______ 1 to 5 (less than part-time)List any Campus Activities/ Community Service Programs in which you are involved: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Financial InformationStudent InformationAre you currently employed? __________ If so, where? _________________________________________________________Number of hours worked per week: _______________________________________Hourly Wage: _____________________2019 income (before taxes) ________________Attach an itemized list: of your school expenses for last year that should include but is not limited to tuition; books; housing; meal plan and food; gas; others; etc. Parent InformationMy Parents are:_____ Married_____ Divorced_____ Separated _____ Unmarried _____ DeceasedFather’s Occupation_____________________________________________________ Place of Employment __________________________________________________ 2019 income (before taxes) _____________Mother’s Occupation __________________________________________________Place of Employment __________________________________________________2019 income (before taxes) _______________Financial Aid HistoryIf you have applied for FAFSA, federal grants, loans, etc., please complete the following section: List any other scholarships or awards that you have received, and their award amounts (i.e. Pell Grants, Bright Futures, Florida Prepaid, other scholarships or loans, etc.): __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Required DocumentationTo be considered for renewal, the following documents, along with this application, must be submitted by Monday, May 11, 2020:An official college transcript of your grades. (unofficial transcripts will not be accepted)A cumulative GPA of 3.00 or higherA copy of any and all financial aid award letters or scholarship award letters.An itemized list of all college expenses.A personal essay updating the scholarship committee of your collegiate and academic experiences and goals. Applicant Certification /Authorization I declare that my responses on this application are true, correct, and complete. I understand the terms and conditions of the scholarship for which I am applying. I hereby authorize release of information contained in this application, my academic transcript and any additional information to the Adrian M. Sample Scholarship Trust. I UNDERSTAND THAT IF MY APPLICATION IS NOT COMPLETE, IT WILL NOT BE CONSIDERED.Student Signature: _________________________________________ Date: __________________IRSC Foundation, Inc. ? 3209 Virginia Avenue, Fort Pierce, FL 34981 ? (772) 462-7246 ................
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