American Netherland Dwarf Club

Application for Roth/Brown Scholarship

American Netherland Dwarf Rabbit Club (ANDRC)

C/O Molly Covert

2300 N Somerset Road, Hudson, MI 49247

Email:

Phone No.: 517-547-4463

Applicant name code: / Click here / (For use by the Scholarship Committee only.)
Important: Read the “ANDRC Scholarships Application Procedures and Advice” document found on the ANDRC website before completing and transmitting this application form!
Important: Complete all sections of this form and, if possible, email it or have it emailed for you to the address above. To be considered for an award, this application must be received at the address above by March 1st. Also, make sure that the required “Post-Secondary School Data Form” and transcripts are received by this date.
I hereby apply for the Roth/Brown Scholarship under the ANDRC Scholarship Program and submit the following information:
1. Name of applicant:
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Last / First / Middle
2. Address of applicant:
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Street / City / State, Zip Code
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Email address / Home phone number / Cell phone number
3. Birth date of applicant: / Click here to enter text.
4. I am currently, and have been a member of the ANDRC since: / Click here to enter text.
Note: For the following sections of this form, High School is defined as grades 9 – 12.
5. Please describe below in your own words, your work activities during your High School and Post-Secondary School years, either for your family, at home, or for outside employers.
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6. List The name and address of the Post-Secondary School that you are currently attending below.
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Name of School
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Street address of School
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City, State, Zip of School
7. Important: If you have earned credits in a Post-Secondary School other than the one you are currently attending list them and the dates (start date and end date) that you attended them below. Also, you are responsible for providing transcripts from those schools to the address at the beginning of this application form. If not, enter N/A below.
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8, What subjects have you found most interesting in your Post-Secondary School work? List two below and state why you found them interesting.
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9. Describe below any special recognitions that you have received for outstanding schoolwork such as honors, prizes, or scholarships for both your High School and Post-Secondary School years.
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10. Please provide below all available test scores (No. and Percentile) of scholastic aptitude.
SAT: / Combined SAT Total Score: / Click here to enter text.
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Verbal (No./Percentile) / Math (No./Percentile) / English (No./Percentile)
ACT (No./Percentile): / Click here to enter text.
Others: List below and if none enter N/A below.
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11. Please provide your High School senior class rank and final GPA below.
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Class rank number / Out of (No. in Class) / GPA
12. Specify below what part you have played in High School and Post-Secondary School activities such as class or other school offices held, band, orchestra, athletics, drama, oratory, school publications, honor societies, etc. Designate in the right hand column the High School grade or Post-Secondary School year in which you participated in each activity as follows: Grade 9, 10, 11, 12 or year 1, 2.
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13. Specify below what part you have played in organized out-of-school activities such as Boy/Girl Scouts, club work, church organizations, etc. Designate in the right hand column the High School grade or Post-Secondary School year in which you participated in each activity as follows: Grade 9, 10, 11, 12 or year 1, 2.
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14. List your favorite recreational activities below.
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15. List your hobbies below.
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16. Have you received any special recognition in connection with your hobbies or recreational activities?
Yes/No: / Click here to enter text. / If Yes, list below. If No enter N/A below.
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17. List below the titles and authors of some of the books you have read during the past three years.
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18. List below the offices you have held or committees that you have been on in rabbit and cavy organizations in the past five years.
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19. List below the most important awards you have won for yourself with your rabbit projects and/or animals.
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20. Explain below how you have helped others by increasing their knowledge of Netherland Dwarf rabbits and also encouraging them to join the ANDRC in the past five years (Demonstrations, TV, radio, etc.).
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21. List below the knowledge that you have acquired about rabbits as the result of your ANDRC membership.
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22. Write a paragraph below on why you want to continue your education. Include educational objectives, field(s) of endeavor, and the reason(s) you have decided on these choices.
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Certification
I have emailed my “Post-Secondary School Data Form” to my Post-Secondary School designated official, or had it emailed for me. By my signature below, I hereby certify: that to the best of my knowledge, all statements contained in this application form are true and correct; that I have read the guidelines, including eligibility requirements, issued by the ANDRC Scholarship Committee; and, that I believe that I am eligible to apply for a scholarship under those guidelines and requirements.
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Signature of applicant (May be typed due to submitting by email) / Date

Page 2 Roth/Brown Scholarship Application Form (April 15, 2014)