1. Full Name:___________________________________________________________

Phone:__________________________email:________________________fax:_________

2. Date of Birth:_____________________________

3. Home Address:_______________________________________________________

________________________________________________________________________

4. Parent(s) Name(s):____________________________________________________

5. Name of institution for which this scholarship is intended:________________________

________________________________________________________________________

6. Most recent grade level, and year of completion:______________________________

7. College major, if declared or decided:______________________________________

8. List all church activities in which you have been involved (include dates):____________

________________________________________________________________________

________________________________________________________________________

9. List any outstanding accomplishments or special honors or awards received during high school and/or college:___________________________________________________

________________________________________________________________________

10. Write a 150-250 word statement (on a separate sheet) giving personal history, evidence of dedication to church, and plans and hopes for the future which will be benefited by receipt of this scholarship.

11. What is the expected annual cost of attending the institution? (Include both tuition and living expenses.)

12. List any other scholarships you have been awarded to date for the academic year in question, and include the amount(s):_________________________________________

________________________________________________________________________

13. Other anticipated financial assistance (amount):

14. Other anticipated income during the academic year in question (from jobs, etc.):

Please attach the following documents:

- a copy of most recent high school or college transcript

- personal references (see Criteria for Carolina Beach Presbyterian Church Scholarships)

- 150-250 word statement (see #10 above)

15. Signature & Date_____________________________________________________