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MLK SCHOLARSHIP APPLICATION |
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Name_________________________________________ (Last) (First) (Middle) |
Birth Date_____________________________ |
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Address_____________________________________________________________________________________ (Street) (City) (Zip Code)
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| Telephone_____________________________________ | Social Security #________________________________
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| High School____________________________________
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| If guardian is other than your parents, please
give guardian information
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| Fathers Name__________________________________ | Mothers Name__________________________________
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| Address_______________________________________ | Address_______________________________________
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| Place of Employment__________________________ | Place of
Employment___________________________
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| Job Title/Position_____________________________ | Job
Title/Position______________________________
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| Gross Income for________________________________ | Gross Income for________________________________
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| High School or GED_____________________________ | High School or GED_____________________________
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| College_______________________________________ | College_______________________________________
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| Graduate?_____________________________________ | Graduate?_____________________________________ |
| Number of dependent children in family_______________ | |
| Number in family, including applicant, that will be in college during coming year_______________________ | |
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Note: Income certification required |
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| In your own words and handwriting, please explain your educational and career aspirations and goals for the future. (Attach an additional sheet if necessary.) | |
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College, university, or institute that you plan to attend. |
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| Name of School_______________________________________________________________________________ | |
| School Address_______________________________________________________________________________ | |
| Have you been accepted?______________ | Pending?___________________ |
| Will you: Live on campus______________ Off campus_____________ Commute______________ | |
| Subject / Degree you plan to pursue______________________________________________________________ | |
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Certification by School Office |
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SAT or PSAT Scores: Date______________________ Math________________ Verbal_____________________ Rank in class________________ GPA________________ Recommendation Superior______________ High______________ Average___________ Low____________ Recommended________________ Not recommended____________ Comments____________________________________________________________________________________ ____________________________________________________________________________________________ Signature of Principal___________________________ |
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Teacher Recommendation Superior___________ High____________ Average___________ Low____________ Recommended________________ Not recommended____________ Comments____________________________________________________________________________________ ____________________________________________________________________________________________ Signature of Teacher____________________________ |
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Certification and Signatures |
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| All information on this form is true and complete to the best of my knowledge. If asked by the scholarship selection committee, I agree to give proof of the information that I have given on this form. | |
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_______________________________________________ _____________________________ Signature of Applicant Date
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_______________________________________________ _____________________________ Signature of Parent / Guardian Relationship Date |
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| Note: Three(3) letters of recommendation are required. (Such as pastor, community, leader, professional person) | |
| Mail or bring completed application to: Mt. Zion Baptist Church, Attn: MLK Scholarship Committee, 950 File Street, Winston-Salem, NC 27101. | |
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| Give a complete description of all scholastic honors and activities and state the year(s) in each case. | |
| Academic honors won in high school______________________________________________________________ | |
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| Extracurricular activities________________________________________________________________________ | |
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| Community / Civic activities_____________________________________________________________________ | |
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| Please list any other information you feel deserves the selection committee attention. | |
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