oaba-duke smith memorial education fund scholarship program

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OABA-DUKE SMITH MEMORIAL EDUCATION FUND APPLICATION FORM (Please type) 1. NAME________________________________________________ AGE ________ 2. ADDRESS_____________________________________PHONE ______________ CITY___________________________________STATE______ZIP_____________ 3. GPA__________________________CLASS RANK_________________________ 4. EMAIL_____________________________________________________________ 5. FATHER’S NAME______________________EMPLOYER____________________ 6. MOTHER’S NAME_____________________EMPLOYER_____________________ 7. NAMES AND AGES OF OTHER FAMILY MEMBERS LIVING AT HOME: NAME AGE _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 6. INDUSTRY AFFILIATION -- PAST & PRESENT: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 7. COMMUNITY OR EXTRACURRICULAR ACTIVITIES: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 8. ACADEMIC PERFORMANCE AWARDS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ 9. SCHOOL ACTIVITIES AND AWARDS: _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________
NAME_________________________________ PAGE TWO 10. LIST THE NAMES OF CLUBS OR ORGANIZATIONS YOU ARE AFFILIATED WITH: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 11. ARE YOU CURRENTLY EMPLOYED?_______ IF SO, WHERE AND HOW LONG? _______________________________________________________________________ _______________________________________________________________________ 12. WILL YOU CONTINUE TO WORK WHILE ATTENDING SCHOOL?______________ 13. WHAT SCHOOL DO YOU PLAN TO ATTEND? _______________________________________________________________________ _______________________________________________________________________ 14. WHAT WILL BE YOUR FIELD OF STUDY?_________________________________ 15. LIST YOUR CAREER GOALS: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 16. CHECK THE TOTAL AMOUNT OF FAMILY INCOME (refer to federal income tax return, Form 1040, line 34): _____ under $14,999 _____ $15,000-$29,999 _____ $30,000-$59,000 _____ OVER $60,000 17. SPECIFY ANY FINANCIAL HARDSHIP YOU MAY BE ENCOUNTERING IN PURSUIT OF FURTHERING YOUR EDUCATION: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ 18. LIST ANY SCHOLARSHIP YOU ARE PRESENTLY OR WILL BE RECEIVING: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________
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oaba-duke smith memorial education fund scholarship program

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