APPLICATION | Website Template- 01

SCHOLARSHIP APPLICATION

A. PERSONAL INFORMATION:

Name

SSN

Address

Country

Phone

Birthday

Month

Day

Year

Age

Gender

Male

Female

Name of Parent(s) or Spouse

College major {Indicate General Studies if undecided)

B. EDUCATIONAL BACKGROUND:

High School

Graduation year

ACT Composite

Your Rank

Number in Graduating Class

High School GPA

GED:

Test Score

Year of GED Test

Note: Minimum score to apply for the GED scholarship is 2800.

Please Check All That Apply:

I have applied for admission to Three Rivers College

I am eligible for the A+ Tuition Program

I am a traditional student (under age 25)

I completed college credits while in high school

I am a non-traditional student (over age 25)

I am a single parent

College freshman (less than 30 semester hours)

College sophomore (more than 30 semester hours)

For the Fall-Spring I Plan to Enroll

Full-time (12 or more hours per semester)

Half-time (6-11 hours per semester)

Less-than-half-time (1-5 hours per semester)

Have you ever attended any college?

Yes

No

Do you have a college degree?

Yes

No

C. FAMILY INCOME INFORMATION: Include Unemployment Benefits, State, Aid, etc ...

Number of persons now living in your household:

How many will be enrolled college (include yourself)

Have you applied for a Pell Grant?

Yes

No

Dependent Students: (under age 25)

Employer | Position Annual | Income

Father

Mother

You (Student)

Independent Students: (adults or married students)

Yourself

Spouse

Do you plan to work while in college?

Yes

No

D. ACTIVITIES & HONORS: (List the most important activities/honors within the last two years)

Civic Activities

Offices Held

School Activities

Honors Awarded

E. SCHOLARSHIPS: I AM APPLYING FOR (check all that apply):

Any Three Rivers academic and/or private scholarships

Service Scholarships:

Three Rivers Ambassador Scholarship (A separate interview will be required)

Three Rivers Cheer Scholarship (Try-outs will be held in Spring)

Three Rivers Music Scholarship (Contact the Music Dept. at S73-840-9639 no later than April 1 to schedule audition)

Three Rivers Student Government Scholarship (Contact the Student Govt. Advisor at 573-840-9609 for more info)

Three Rivers Resident Assistant (Contact housing at 573-840-9106 for more info)

F. OTHER INFORMATION:

1. Are you a member of the Poplar Bluff Federal Credit Union?

Yes

No

2. For Students Enrolled in Allied Heath Programs

I have been officially accepted into the:

Three Rivers Nursing Program: Poplar Bluff Campus

Three Rivers Nursing Program: Sikeston Campus

Medical Lab Tech Program

Paramedic Program

3. Are you planning to live on-campus?

Yes

No

4. Displaced Homemaker: (Displaced homemakers are divorced, widowed, separated or have disabled spouses who must prepare for paid employment. They have worked primarily without pay to care for the home and family.)

I have worked primarily without pay to care for a home and family and for that reason have diminished job skills.

5. Armed Services: ls/Was your spouse, parent, grandparent, great-grandparent, son or daughter a veteran of the US Armed Services?

If yes, give their name & Relationship (to you)

Branch of service & Number of years in service

Are you a Veteran of the US Armed Services?

Yes

No

Will You receive Veterans Educational benefits?

Yes

No

Did above individual serve in a foreign war:

Yes

No

G. ESSAY: Essay is required.

IT MUST BE TYPED, AT LEAST TWO PARAGRAPHS BUT NO LONGER THAN ONE PAGE.

Your name must be typed in the upper right corner. This is a critical element of your application. Neatness, spelling and grammar are

very important.

1. Why is an education important to you? Describe your educational plans, career choice and future goals. Also note any special

circumstances that may impact your educational plans.

2. Resumes are not part of this scholarship application - please do NOT enclose a resume.

File upload

APPLICANT SIGNATURE (required)

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This is a confidential form. Information provided on this application is used to determine your eligibility for any institutional and/or private scholarship awards. • With my signature I certify that all information provided is to the best of my knowledge true and complete and I have not willingly or knowingly withheld information. I grant permission for the Foundation to release this information as well as academic information to the scholarship donors if required. It is the policy of this foundation not to discriminate based on race, color, sex, age, religion, handicap, or other non-merit factors.

For more information about scholarships: TRCC Foundation, PO Box 283, Poplar Bluff, MO 63902