O. T. Smallwood Scholarship Application
Immanuel Lutheran College
National Alumni Association
Greensboro, North Carolina
STUDENT DATA Date___________________
Name: Last_____________________________________ First____________________________ Middle________________________
Street Address___________________________________________________________________________________________________
City_________________________________________________ State_______________________ Zip Code_____________________
Date of Birth_____________________Home Telephone Number_____________________ Cell Number_________________
U. S. Citizen or Permanent Resident __________YES _________NO Currently a citizen
resident of ____________________________________________
HIGH SCHOOL DATA
_____________________________________________________________________________________________________________________
Name of High School Currently Attending
_____________________________________________________________________________________________________________________
Street Address
______________________________________________________________________________________________________________________
City State Zip Code
Cumulative GPA __________based on a _____________point scale ____________________
Graduation Date (m/y)
Class Rank _________of ______ _______ _________ ______ ___________
SAT Scores Writing Verbal Math ACT Composite
Most Recent High School Transcript Must Accompany This Application.
I am applying for the O. T. Smallwood Scholarship Award. I understand that if I meet the requirements as described in the Scholarship Criteria, I will be eligible to receive only one award under the provisions of this program.
Page 1 of 4 Scholarship Application Revised 8/23/10
COLLEGE/UNIVERSITY DATA
____________________________________________ ______________________
Name of Institution Applying to Major
_______________________________________________________________________________
Address
____________________________________________ _____________________________
Name of Institution Applying to Major
____________________________________________________________________________
Address
____________________________________________ ___________________________
Name of Institution Applying to Major
____________________________________________________________________________
Address
EXTRACURRICULAR ACTIVITIES
List school and community activities in which you have participated in the past three years.
Activity Position Hours Per Week
____________________________________ ____________________ ________________
____________________________________ ____________________ ________________
___________________________________ _____________________ _______________
HONORS AND AWARDS
______________________________________________________________________________
Employment History
Name of Employer Location Dates Job Title/Description
__________________________ ________________ __________ _______________________
__________________________ ________________ __________ _______________________
________________________ _________________ __________ _______________________
Page 2 of 4 Scholarship Application Revised 8/23/10
HOUSEHOLD FINANCIAL DATA (All financial information will be kept confidential.)
Number of people in your household ______________________
Number of household members currently attending college _______________
FUNDING SOURCES
Please indicate expected sources of funding for your first year of college in percentages (e.g. 50%). Total from all sources should equal 100%.
Family, Relatives ________ Scholarships/Grants_______
Personal Savings ________ Loans _______
Other (specify) _______ Job/Work Study _______
Comment on any special financial circumstances that the selection committee should consider.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indicate any factors influencing your decision to apply for this scholarship. Check the appropriate anwer/s.
_____School Counselor Teacher______ Family______ Friends ______
_____Other (please specify) ________________________________________________
REFERENCE LETTERS
All applicants are required to provide two letters of reference from either a teacher, other school personnel; community representative, or previous employer. The letter should address the applicant’s demonstrated ability in academics, extracurricular activities, character and leadership qualities. They shall be submitted in sealed envelopes with the application.
Page 3of 4 Scholarship Application Revised 8/23/2012
ESSAY QUESTIONS
Write a 200 word essay answering ONE of the following questions:
Page 4of 4 Scholarship Application Revised 8/23/2012
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Immanuel Lutheran College
National Alumni Association
Greensboro, North Carolina
STUDENT DATA Date___________________
Name: Last_____________________________________ First____________________________ Middle________________________
Street Address___________________________________________________________________________________________________
City_________________________________________________ State_______________________ Zip Code_____________________
Date of Birth_____________________Home Telephone Number_____________________ Cell Number_________________
U. S. Citizen or Permanent Resident __________YES _________NO Currently a citizen
resident of ____________________________________________
HIGH SCHOOL DATA
_____________________________________________________________________________________________________________________
Name of High School Currently Attending
_____________________________________________________________________________________________________________________
Street Address
______________________________________________________________________________________________________________________
City State Zip Code
Cumulative GPA __________based on a _____________point scale ____________________
Graduation Date (m/y)
Class Rank _________of ______ _______ _________ ______ ___________
SAT Scores Writing Verbal Math ACT Composite
Most Recent High School Transcript Must Accompany This Application.
I am applying for the O. T. Smallwood Scholarship Award. I understand that if I meet the requirements as described in the Scholarship Criteria, I will be eligible to receive only one award under the provisions of this program.
Page 1 of 4 Scholarship Application Revised 8/23/10
COLLEGE/UNIVERSITY DATA
____________________________________________ ______________________
Name of Institution Applying to Major
_______________________________________________________________________________
Address
____________________________________________ _____________________________
Name of Institution Applying to Major
____________________________________________________________________________
Address
____________________________________________ ___________________________
Name of Institution Applying to Major
____________________________________________________________________________
Address
EXTRACURRICULAR ACTIVITIES
List school and community activities in which you have participated in the past three years.
Activity Position Hours Per Week
____________________________________ ____________________ ________________
____________________________________ ____________________ ________________
___________________________________ _____________________ _______________
HONORS AND AWARDS
______________________________________________________________________________
Employment History
Name of Employer Location Dates Job Title/Description
__________________________ ________________ __________ _______________________
__________________________ ________________ __________ _______________________
________________________ _________________ __________ _______________________
Page 2 of 4 Scholarship Application Revised 8/23/10
HOUSEHOLD FINANCIAL DATA (All financial information will be kept confidential.)
Number of people in your household ______________________
Number of household members currently attending college _______________
FUNDING SOURCES
Please indicate expected sources of funding for your first year of college in percentages (e.g. 50%). Total from all sources should equal 100%.
Family, Relatives ________ Scholarships/Grants_______
Personal Savings ________ Loans _______
Other (specify) _______ Job/Work Study _______
Comment on any special financial circumstances that the selection committee should consider.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Indicate any factors influencing your decision to apply for this scholarship. Check the appropriate anwer/s.
_____School Counselor Teacher______ Family______ Friends ______
_____Other (please specify) ________________________________________________
REFERENCE LETTERS
All applicants are required to provide two letters of reference from either a teacher, other school personnel; community representative, or previous employer. The letter should address the applicant’s demonstrated ability in academics, extracurricular activities, character and leadership qualities. They shall be submitted in sealed envelopes with the application.
Page 3of 4 Scholarship Application Revised 8/23/2012
ESSAY QUESTIONS
Write a 200 word essay answering ONE of the following questions:
- What are your education goals and how do they relate to your career objectives?·
- How have extracurricular and/ or community activities shaped your life?
Page 4of 4 Scholarship Application Revised 8/23/2012
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