Atlanta - Downtown Chapter

Application for Scholarship

Deadline Date: June 15, 2006

Name_________________________________________________________________________________ Current Address (line 1)________________________________________ Date of Birth ________________ Address (line 2) ______________________________________________ SSN ______________________ Telephone# (home)____________________________________________ (school) ___________________ Parent/Guardian ________________________________________________________________________ Permanent Address (if different from current) Address (line 1) ________________________________________________________________________ Address (line2) ________________________________________________________________________ Name of High School ____________________________________________________________________ Address of High School (City & State) _______________________________________________________ Name of Guidance Counselor ______________________________________________________________ High School Grade Point Average _________________ Honors, Awards, or Recognitions __________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ School Activities ______________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Other Activities (Community, Religious, etc.) __________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Proposed Major _________________________________ Classification ___________________________ I certify that the above information is true and correct. Applicant's Signature _________________________________________________Date: ___/___/____ Parents' / Guardian's Signature __________________________________________Date: ___/___/____