Name_________________________________________________________________________
(Last) (First) (Middle)
Social Security # _______________________________________________________________
Permanent Address
____________________________________________________________
(Number) (Street) (City) (# of Yrs)
Phone_______________________ E-Mail Address__________________________________
______________________________________________________________________________
EDUCATIONAL BACKGROUND
1. Last High School Attended
______________________________________________________________________________
(Name) (City & State) (Dates –from/to)
2. Date you will complete or have completed high school. ____________________________
______________________________________________________________________________
3. List special interests, activities, honors, awards, offices held, etc.____________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Rank in class _____________________________________(example – 25th in class of 400)
5. Cumulative grade point average _____________ (Please attach sealed official transcript)
Grade point average in a ____________point scale.
6. Institution you plan on attending or are currently attending:
_______ Lewis University – Hickory Hills, IL ______ Moraine Valley – Palos Hills, IL
7. Please check the appropriate:
_____ I have been accepted (Please attach letter of acceptance)
_____ I have attended from _____ to _____ (Please attach sealed official transcript)
and have completed _____semester/quarter hours.
8. What is your major area of study? ____________________________________________
9. Explain your reasons for applying for this scholarship ____________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
10. What percent of your education expenses will be provided for by your family? ________
___________________________________________________________________________
11. What additional financial support do you anticipate (include grants, scholarships, part-
time or full-time employment, employer incentives, etc.____________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
12. What are your career plans? __________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
| Serving the Communities of Hickory Hills and Palos Hills P.O. Box 1164 Bridgeview, IL 60455-1164 Ph (708) 364-7739 Fax (708) 364-7735 E-Mail: info@thehillschamber.com www.thehillschamber.com |
HILLS CHAMBER OF COMMERCE SCHOLARSHIP APPLICATION |
| APPLICANT’S PERSONAL AND FAMILY BACKGROUND |
1. Date of birth _______________________________________________________________
2. I have been a resident of Hickory Hills or Palos Hills for _____________________ years.
3. Marital status ______________________________ (if single, skip questions 5 through 9).
4. No. of children _________________ ages ________/_______/_______/_______/________
5. Spouse’s name _____________________________________________________________
6. Spouse’s address (if different from applicant)
__________________________________________________________________________
(Number) (Street) (City) (State) (Zip Code)
7. Spouse’s occupation _________________________________________________________
8. Spouse’s employer __________________________________________________________
9. Spouse’s monthly gross income _______________________________________________
10. List all employment that you have held.
Dates Employed Nature of Work Employer
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
11. Are you presently employed ____________ so how many hours per week ____________
12. Father or Guardian _________________________________________________________
Address ___________________________________________________________________
(Number) (Street) (City) (State) (Zip Code)
Occupation ________________________ Employer ______________________________
Years employed by present employer ________________
13. Mother or Guardian ________________________________________________________
Address ___________________________________________________________________
(Number) (Street) (City) (State) (Zip Code)
Occupation ________________________ Employer ______________________________
Years employed by present employer ________________
14. Number of dependent children in the family (not including yourself) ________________
Ages _______/_______/_______/_______/_______/_______
15. Please explain any unusual family circumstances, expenses or indebtedness that should
be considered ______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
16. Please include any additional information you would like the scholarship committee to
consider ___________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I affirm the correctness of my answers and the information provided on this application and supporting
documents. I understand that any false answers provided in this application may disqualify me from
consideration.
____________________________________________ _________________________
(Signature of Applicant) (Date)
STATEMENT OF PARENT OR GUARDIAN
(If applicant is under 18 years of age)
I have read the above application in full and hereby state that to my knowledge it is accurate and complete.
________________________________________________ ____________________________
(Signature of Applicant) (Date)