Common Application Form for Selected Scholarships

2014-2015 Academic Year

PLEASE NOTE: This application is to be used ONLY if you are applying for one or more of
the scholarships listed below:
 Pieter Smit Memorial Scholarship
 Gregory Fotia Memorial
Scholarship  Neumann Enterprises, Inc. dba:
 Hilton Head Area Home Builders Servpro of Beaufort County  Rotary Club of HHI
Association Scholarship
 Thomas Heyward, Jr. Scholarship
 Italian-American Club/Francis  Dr. Robert Bokat Humanitarian
 Women’s Association of Hilton
Mastridge Scholarship Scholarship
Head Community Service Award
 Military Officer’s Association of  Okatie Rotary Club Scholarship
 VanLandingham Rotary Club
America Scholarship  Palmetto Quilt Guild Scholarship Scholarships
These scholarships are available to high school students and home-schooled students. This scholarship
application form must be submitted to each selected scholarship provider or to your school’s Guidance
Office, if the school has agreed to receive applications for the scholarship provider. See General Instructions
below for additional information about completing this application. You can find specific information about
each scholarship at www.lowcountryscholarshipdirectory.org or from your school’s Guidance Office.
General Instructions to Applicant
1. Make a copy of the blank application form and complete a draft copy first.
2. Return a typed or neatly printed application to your high school guidance counselor by the deadline due
date. This application is the first impression you will make upon those who award scholarships.
3. Check with your guidance counselor and/or the scholarship provider concerning additional
requirements. Certain scholarships require additional information such as the FAFSA application,
written essays, or specific financial documents.

1. Personal Information
Full name of applicant Nickname
Home telephone number Email address
Present home address
City State Zip
Number of years lived in Beaufort County Citizenship
Date of birth Social Security Number
2. Family Information
Mother’s name Father’s name
Occupation Occupation
Street address Street address
City,ST,Zip City,ST,Zip
Phone number Phone number

Name and ages of siblings/other dependents. Indicate what school(s) they attend.
Name Relationship Age School or college/years attended

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3. Education
a. Name all secondary and/or technical schools you have attended in the last five years. List the school
you are presently attending first.

b. How many years do you plan to attend college, and what course of study would you like to pursue?

c. What future business or educational career will you likely pursue after finishing college?

d. What college(s) would you most like to attend? Please explain your reason.

e. What colleges have you applied to for admission? Please indicate acceptance status.

f. List scholarships, grants or loans for which you have applied, and check the ones you plan to use.
Indicate funding amount you will receive.
Name Amount Plan to use

4. Academic, athletic, service, and extra activities. Use additional pages or

attach resume for sections 4a, 4b, and 4c.
a. List academic awards, achievements and dates.

b. List participation in athletic activities.

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 c. List participation in community service and extra-curricular activities.

5. Employment History
List jobs you have held in the last three years.
Employer Dates Hours per week Position Salary

6. Your Expected Cost of College:

Please provide the following information for each school that you apply.

College College College College

Tuition

Room/board

Books/supplies

Clothing/personal

Entertainment

Transportation

Scholarship
money
available?

Total Annual Cost

7. Financial Need Summary

Complete this section regarding Estimated Combined Net Income of you, your parent(s) or guardian(s)
for the current year. Please attach a copy of your and your parent’s most recent Federal Income Tax
statement to the back of this application form.
Name of person Income and year Total annual income

b. Have you filed a FAFSA (Free Application for Federal Student Aid)? If so, please submit a
returned copy showing your EFC (expected family contribution).

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 c. Describe any special circumstances such as medical conditions, disabilities, etc. that may affect your
ability to pay for your college tuition. Use additional pages if necessary.

8. Transcript History
This section is to be completed by your principal or guidance counselor. Attach a certified transcript of
the student’s high school record to this sheet.

Ranking in senior class: of

GPA: _____________ on a _______________ scale
Best Combined SAT Score: Verbal Math Writing

Best ACT Score: Date ____________ Score ________________

Signature of principal or guidance counselor

I do state the above information is accurate to the best of my knowledge.

Signature of Applicant

Date

NOTE: This scholarship application form must be submitted to each selected scholarship provider or to
your school’s Guidance Office, if the school has agreed to receive applications for the scholarship provider.

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