Illinois Grand Assembly
Application for Scholarship
Date________________________
This scholarship is being requested for the semester beginning (mmddyy) _____________
Name_____________________________________________________age_______
address_____________________________________________________________
social security #___________________ phone___________________________
high school attended___________________________________________________
class rank _____of_____ GPA ______on ______scale ACT score_______
parent or legal guardian________________________________________________
parent address________________________________________________________
Mother’s occupation____________________ Father’s Occupation______________
net combined family income____________________________________________
please explain why you need this scholarship _________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
other scholarships and loans received and amount ______________________________
____________________________________________________________________
your course of study in college__________________________________________
present plans regarding your career after college ______________________________
___________________________________________________________________
Name and address of college where scholarship payout should be sent
______________
___________________________________________________________________
___________________________________________________________________
I hereby make voluntary application for this scholarship.
The data I have submitted is correct to the best of my knowledge.
________________________________________________________________
applicant signature
parent signature