Scholarship Application

(Please Type or Print in ink)

1. Name:____________________________________ Call:_____________ Age:___________

2. Birthplace:___________________________________Date of Birth:____________________

3. Residence:_________________________________________________________________

Phone (Home) ( ___ )_________________________(Work) ( ____ ) ____________________

4. Mailing Address:____________________________________________________________

___________________________________________ Phone ( ____ ) ___________________

5. Name of nearest living relative: _________________________________________________

Address:____________________________________________________________________

City: _____________________ State: ___________ Zip ___________ Phone: (___) ________

6. What high school did you attend? __________________________Location: _____________

Graduated what percentage of class? _________ Grade Point Average ____________________

Please provide a copy of high school transcript

7. Are you now attending a college or technical school?________________________________

Name:______________________________________________________________________

Location:____________________________________________________________________

8. At which school have you been accepted and plan to attend?___________________________

Location:____________________________________________

9. College entrance scores:(types and subjects) SAT Verbal_____________________________

SAT Math________________ACT Score________________Other_____________________

10. List other schools or universities attended, degrees earned and dates attended:_____________

___________________________________________________________________________

11. Indicate grade point average (GPA) for each year beyond high school. 1 _____ 2 _____

3 ______ 4 ______ If GPA is based on other than 4.0, explain___________________________

12. While in college, have you been on the Dean's list or similar Honor Roll? _________________

Number of semester(s) or quarters:_______________

13. Are you presently or will you be the beneficiary of any other scholarship or grants?__________

donor(s)________________ amount this year________________________________________

14. What do you estimate your total schooling costs to be in the next school year?

Total costs:_________________Tuition:_________________Room and Board:_____________

Books and supplies:______________ Other (explain)__________________________________

15. What is your major field of study?______________________________________________

What is your minor if any?_______________________________________________________

16. What degree do you expect to receive from your proposed course of studies?_____________

___________________________________________________________________________

17. Why have you selected this field of study?________________________________________

__________________________________________________________________________

18. What would you like to do as a life's work?______________________________________

__________________________________________________________________________

19. Why do you feel a need for this scholarship?______________________________________

__________________________________________________________________________

20. List current amateur license information: Call Sign_______________Class_______________

First date of issue:___________________ Expiration date:_____________________________

Other licensed amateurs in your family:_(name and call)________________________________

__________________________________________________________________________

21. Are you operating at present?____________If yes, what modes and bands?______________

___________________________________________________________________________

22. Has your amateur license ever been suspended or revoked?___________________________

If yes, explain_________________________________________________________________

23. Have you ever been convicted of a felony?________________________________________

If yes, explain_________________________________________________________________

24. Are you a member of ARRL___________ARES_____________RACES_______________

25. List any radio club(s) you are or have been a member of and any offices held:______________

___________________________________________________________________________

26. What aspects of ham radio interest you the most and how active are you in them?___________

___________________________________________________________________________

27. What do you feel, as an amateur, you can contribute to the betterment of amateur radio?

__________________________________________________________________________

28. List other hobbies and activities:_______________________________________________

__________________________________________________________________________

29. List past and present employment:

Firm name and address: ......................Nature of work.....................Dates.............Hour/Week

___________________________________________________________________________

30. List school, scholarship, and civic awards you have received:

___________________________________________________________________________

31. List other activities in which you are involved:______________________________________

___________________________________________________________________________

32. List name, home address, and home phone for the following references who must not be related to you:

ACADEMIC REFERENCE:_____________________________________________________

Home address:________________________________________________________________

Home Phone:__________________

CHARACTER REFERENCE:___________________________________________________

Home address:_______________________________________________________________

Home phone:__________________

NEIGHBORHOOD REFERENCE:_______________________________________________

Home address:_______________________________________________________________

Home phone:__________________

The information contained in this application is true and correct to the best of my knowledge.

Signed:_______________________________Call___________________Date____________