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|[pic] |Rudolph Canzater Scholarship Application |

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| |Application Deadline: June 9, 2017 (postmark date) |

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| |(Please Type or Print) |

|Eligibility Requirements:  |

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|Applicant must be a resident of the Sixth Congressional District of South Carolina, and plans to attend college in the academic year of 2017-2018.  Additionally, applicant|

|must have a minimum GPA of 2.0 on a 4.0 scale, demonstrate a financial need, and be classified as an entering freshman at an institution of higher learning in the fall of |

|2017. |

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|The application MUST be filled out in its entirety. |

|Part A: Personal Data |

|Last Name: |First Name: |Middle Initial: |Age:    |

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|Social Security Number: - - |Sex: M F |Date of Birth: / / |

|Permanent Address (Street): |Apt. # |

|City: |State: |Zip Code: |

|Alternate Mailing Address: |

|City: |State: |Zip Code: |

|Telephone Number: ( ) - |Cell Number: ( ) - |

|E-Mail Address: |Congressional District: |

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|How did you hear about the program? Website Student Organization Other: |

|Part B: Educational Background |

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|Name of high school currently attending: |

|City: |State: |Zip Code: |

|Expected graduation date: |GPA: |

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|Name of College you are planning to attend in the fall of 2017: |

|Part C: Work Experience/Summer Internships/Community Service |

|Company/Organization: |Dates Employed: |

|Duties/Responsibilities: |

|City: |State: |Zip Code: |

|Company/Organization: |Dates Employed: |

|Duties/Responsibilities: |

|City: |State: |Zip Code: |

|Part D: Financial Information (Please Provide Proof of Income)-FAFSA PRINT OUT |

|Financial Assistance Received or Pending To Date |

|Scholarships and/or grants awarded or pending (please specify amounts): |

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|Loans or other income: |

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|Information About Your Parents- *MUST BE COMPLETED* |

|Father’s Name: |Occupation: |

|Employer: |Total Annual Salary: |

|Mother’s Name: |Occupation: |

|Employer: |Total Annual Salary: |

|Number of parents’ dependent children (including yourself): |

|Number of parents’ dependent children in college (including yourself): |

|Part E. Additional Information |

|Extracurricular Activities: |

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|Honors and/or Special Recognitions Received: |

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|Application Check List |

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|Applications missing any of the required materials below will not be considered. |

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|In one envelope, please include: |

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|Completed application form |

|A copy of your official high school transcript with signature and school seal. |

|A copy of college acceptance letter |

|Essay indicating your career goals and how this scholarship will assist you with meeting those goals. (Essay must be typed and should not exceed 500 words.) |

|A recent 4x4 color photograph (please print your name on the back) |

|Proof of Income (FAFSA PRINT OUT) |

|Certification & Usage of Photograph Authorization |

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|Certification |

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|I hereby certify that all information provided in this application is true and accurate. I am aware that any misrepresentation will result in the disqualification of my |

|application. |

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|____________________________________________________ ______________ |

|Signature of applicant Date |

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|Photograph Usage Authorization |

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|If selected as a scholarship recipient, I hereby authorize the James E. Clyburn Research & Scholarship Foundation and/or the Rudolph Canzater Scholarship Committee to use |

|the enclosed photograph in any print or electronic announcements of scholarship awards. |

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|____________________________________________________ ______________ |

|Signature of applicant Date |

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|If you have any questions, please contact Janice Marshall 803-255-0003. Completed applications and required enclosures must be postmarked by June 9, 2017, please mail to:|

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|James E. Clyburn |

|Research & Scholarship Foundation |

|Post Office Box 12548 |

|Columbia, SC 29211 |

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In one envelope, please include one copy of each the following materials in the order listed

Completed application form

One page resume listing extracurricular activities, honors, employment, community service experience, and special skills

Responses to two essay questions

A copy of your official high school or college transcript

Two letters of recommendation

A recent photograph

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