Application for Scholarship Award

                                                         (PLEASE PRINT OR TYPE)

             TRANSCRIPT OF SECONDARY SCHOOL GRADES AND CONFIDENTIAL STATEMENT

                                               MUST ACCOMPANY THIS APPLICATION

1.______________________________________________________________________________________                   Last Name                                         First Name                               Middle Name

2.       ____________________________________________________________________________________                Residence                                       Telephone                                            Birth Date

3.         ____________________________________________________________________________________               Father's Full Name                                                                          Mother's Full Name

4.         ____________________________________________________________________________________                     School You Now Attend

5.  List the Schools or Vocational Institutions that have accepted you, in order of preference:

            A.__________________________________________________________________________________

            B.__________________________________________________________________________________

            C.__________________________________________________________________________________

6. Course of Study now pursued by you:

_____________________________________________________________________________________

             _________________________________________________________________________________

7.  Course of Study planned for college:

_____________________________________________________________________________________

            ____________________________________________________________________________________________

Please answer questions 8 through 11 in detail.  Use a separate sheet of paper, one side only, but as many as you need to give complete information.

8.   Have you applied for and/or received any other grants or scholarships?

9.   Will you receive any financial help from any source, including your parents?

10. Have you had income from employment or do you plan to work to assist in financing your    education?

11. Any extra curricular activities while in secondary school?

 ___________________________

Date

Mail Application with Transcript and the Parent's or Guardian's Confidential Statement by APRIL15, 2009 to:

                                                              SCHOLARSHIP COMMITTEE

                                                             ROTARY CLUB OF PEABODY

                                                                           P.O. BOX 94

                                                                    PEABODY, MA 01960

                                                                                                          Page 1

ROTARY CLUB OF PEABODY

Parent’s or Guardian’s Confidential Statement

(PLEASE PRINT OR TYPE)

Supporting Data for

               ________________________________________________________________________

          Applicant’s Name

            ________________________________________________________________________

           Parent/Guardian’s address (if different)           Telephone (if different)

This form is to be completed and signed by applicant’s parent or guardian.  Since the award of Scholarships is based as much on character and the evidence of financial need as upon scholastic superiority, you are requested to supply the following information about the funds available for the applicant’s education.  Information thus given will be shown only to the members of the Scholarship Committee and will be considered in strict confidence.

Your Relationship to Applicant:

          _________________________________________________________________________

Your Occupation or Position:

         __________________________________________________________________________

Spouse’s Occupation or Position:

         __________________________________________________________________________

Your Employer’s Name & Address:

         __________________________________________________________________________

Spouse’s Employer’s Name & Address:

         __________________________________________________________________________

Combined Gross Annual Income:

         __________________________________________________________________________

Number of School Children & Ages:

        __________________________________________________________________________

The Committee will welcome any further statement you may wish to make which may aid in determining the applicant’s need.  Please use a separate piece of paper if needed.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

_________________________________                                       _________________________

Signature of Parent/Guardian                                                                       Date

Mail Confidential Statement along with the Student’s Application by April 15, 2009 to:

                                                Scholarship Committee

                                                Rotary Club of Peabody

                                                P O Box 94

                                                Peabody, MA 01960

                                                            Page 2