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Southwest Indiana Chapter Scholarship Application

Southwest Indiana Chapter: Scholarship Application
Applicant Information
First Name:
Last Name:
Parent(s) Name:
Address 1:
Address 2:
Zip/Postal Code:
County of Residence:
Phone Number:
Father's Occupation:
Mother's Occupation:
Combined income of parents before taxes:
Please state any extenuating circumstances regarding your financial need:
Family Background
Number of children in family and their ages:
Number currently attending college:
Education Information
High School:
Class Rank
out of
SAT and/or ACT Score:
Colleges Attended:
Credits Earned:
Planned College Major:
Plans after College Graduation:
High School Graduation Date:
Give specific information of any honors, awards, offices held, etc., during high school and college:
List activities and organizations other than school and your specific involvement:
Work Experience
Jobs held outside school hours and number of hours worked:
Full time jobs held:
From what other sources do you expect to receive financial help?
Final Information
Name and phone number of two references (not related to the applicant) who would be willing to provide recommendations:
1st Reference
2nd Reference
If we did not give you enough space to expand on your answers as much as you might have wished, please use this box to tell us more.
You may use this form in one of two ways:
  1. The simplest way would be to complete and submit it online, and it will be forwarded to the appropriate county scholarship chairperson.
  2. You may wish to fill in the blanks on your computer, print the completed form and mail it, especially if you want to include additional pages.

Visit the Scholarships page for mailing addresses for the scholarship chairpersons from the various counties.

You will aid the Scholarship Committee in its selection by giving us as much information as possible.

Completed applications must be received by April 1, 2014.

  • If you will be submitting your application through the mail, don't hit either button. Just print the page from your browser.