ROBERT AND MIRIAM HARTZELL SCHOLARSHIP FUND

MERIT SCHOLARSHIP APPLICATION FOR HIGH SCHOOL SENIORS

Name______

Address______

City______State______Zipcode______

Phone ______Email______

Father’s Name______

Address______

Employer______

Mother’s Name______

Address______

Employer______

Total Parental Income [from line(s) 33 on 1040, line(s) 4 on 1040 EZ, or line(s) 18 on 1040A of the most recent tax form(s) filed with the Internal Revenue Service].

_____Below $30,000.00_____$90-120,000.00

_____$30-60,000.00_____$120-150,000.00

_____$60-90,000.00_____Over $150,000.00

List other children of each Parent:

NameAgeSchool/College attending

______

______

______

______

Name of your High School______

Your GPA_____ SAT Score______ACT Score______Class Rank______No. in Class______

Specify any significant family/personal circumstances that should be considered:

List significant school activities:______

______

______

______

______

______

List significant community activities:______

______

______

______

______

______

List any special awards, recognition or achievements received in grades 9-12:

______

______

______

______

______

List any employment you have experienced, naming employer & type of work:

______

______

______

______

What are your goals for college and why did you choose them?______

______

______

______

______

______

What are your goals for your life after college?______

______

______

______

______

______

What do you consider your biggest or most important accomplishment in high school, and why do you consider it to be significant? (It not need be academic or extra-curricular; limit yourself to the space below.) ______

______

______

______

______

______

Your income for last year: $______Your total savings: $______

Specify total assets available to you from additional account(s) established for

the benefit of your educational or college expenses: $______

Specify any applicable payments/credits for you this coming year from other sources (i.e., college assistance, other scholarships) $______

Specify the college you plan to attend and the total budgeted tuition, room & board for the coming year:

1st choice______$______

2nd choice______$______

GENERAL CRITERIA FOR CONSIDERATION: Leadership achievement and potential, scholastic achievement and potential, financial need and character assessment.

ON OR BEFORE MARCH 15, 2016, Return completed application

to your Guidance Counselor.

Please include a copy of your high school transcript.

Applications that are received after March 15, 2016,

or are incomplete will not be considered.

This scholarship may be renewable for three additional years contingent upon a 3.0 G.P.A. and an annual application.

Revised 2016

1