APPLICATION FOR JEFFERSON RURITAN SCHOLARSHIP

   PART I.

       Name____________________________________________ Date______________________

       Address_____________________________________________________________________

       City___________________________________  State______________  Zip______________

       School________________________________________ Graduation Date________________

       College/Vocational School Planning to Attend

       _____________________________________________________________________________

      Name of parent/grandparent member of Jefferson Ruritan________________________________

       ------------------------------------------------------------------------------------------------------------------------

       PART II.

       1.     What are your career goals?

2.      How have you prepared yourself to achieve your goals?

3.    What other factors do you feel should be considered  which could influence your selection for a scholarship?

Please answer each question completely on a separate sheet of paper and forward your answers, along with this application and any supporting documentation (see Fund Guidelines), to your guidance office or Jefferson Ruritan, by the deadline date of April 1^st. 

       ----------------------------------------------------------------------------------------------------------------------

       Signature of Applicant________________________________________________________