Please type or print the information requested:
Contact/Personal Information
1. Name ______________________________________
2. Permanent Address ____________________________
County of Residence____________________________
City, State, and Zip ____________________________
3. Telephone Number (home)____________(work)_______(cell)________
4. Email____________________________
5. Date of Birth _____________
6. Married/Divorced/Single (circle one)
7. Do you have legal dependents that receive more than half of their support from you? Yes____ No____
8. If yes, how many? ____
9. Are you the legal dependent of someone else? Who and what is the relationship? _________________________________________
10. Do you work? Where and how long?__________________________.
11. Please state your net (take home) income for the last two years:
Last Year____________ This Year______________
Educational History/Information
1. High School attended_________________
Date of graduation ________ GED____________
Education completed beyond high school: ______________________
2. Are you currently attending an educational institution? _________
Name of institution______________ Academic Standing____
*Please enclose a transcript
3. If not currently enrolled, where do you plan to attend? ______________
4. What is your classification? ____Freshman___Sophomore
_____Junior_____Senior_____Other
5. What is your enrollment status? ___Full time___Part time
6. What is the degree, license, or certificate you will receive upon
completion of your studies? _________________________
7. When do you expect to complete your degree/certificate? ______________
In the space below or on a separate sheet, please explain why you should be
awarded this scholarship._____________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Please provide the name, address, and phone number of three references
who have known you for at least three years, excluding relatives:
Name__________________Address__________________Phone________
Name__________________Address__________________Phone________
Name__________________Address__________________Phone________
I attest that all information provided by me, the applicant for this scholarship
is complete and accurate to the best of my knowledge.
__________________________________ _________________
Signature of applicant Date
Please return to: Zonta Club of Seguin
Scholarship
PO Box 1994
Seguin, Tx 78155