Association of Arkansas Counties Scholarship Application


ASSOCIATION OF ARKANSAS COUNTIES SCHOLARSHIP APPLICATION


Applicant’s Name: Permanent Address: City, State, Zip: Age:


Marital Status:


Home Phone Number: Are you currently employed? Yes


Name of current/last employer (if any)? Position:


Yes:


Number of Dependents: No


Salary/Wages:


Are you a child, grandchild, adopted child or stepchild of a current or retired county employee of Arkansas? No:


If yes, name of relative Which county? Department relative employed: Relationship to county employee:


Source and amount of funds available for year in which scholarship is requested: REQUIRED INFORMATION $ $ $ $ $ $


Parents projected income: Own projected income:


Scholarships (current or anticipated): Government Grants: Personal Savings:


Other (i.e. spouse income):


Have you previously received assistance from the Association of Arkansas Counties Scholarship Trust? Yes:


No:


Educational Institution Applicant is now Attending: Institution Name: City, State, Zip: Major:


Academic Classification (check one) High School Senior


College Freshman College Sophomore


Educational Institution in which enrollment is desired: Institution Name: City, State, Zip: Course of Study:


Expected Date of Completion: Amount of tuition/fees per semester:


$


By my signature, I hereby authorize the Association of Arkansas Counties or its agents to make inquiry as to my enrollment status at the educational institution noted above and to seek reimbursement of scholarship funds should I fail to attend a qualifying educational institution.


Signature Date


Updated 2009


Grade Point (on a 4.0 scale): Highest ACT or SAT Score:


College Junior College Senior


Graduate Student Other


Degree Sought:


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