1. NAME: Last, First, Middle

2. HOME ADDRESS:

Street:

City:State:Zip Code:

County:

3. Telephone Number: (Include Area Code)

4. Birth date: / / Social Security #--

5. Sex: Male , Female # of years a residence in Harrison County
 
 

6. Names of Parents or Legal Guardian(s):

Father: Employer: 

Mother:Employer: 

Family Income:  $5,000 -$25,000  $25,000 - $50,000 

$50,000. - $75,000  $75,000 - $100,000  $100,000 - $150,000

$150,000 - $200,000  $200,000 +
 
 

7. Name of COLLEGE or SCHOOL that you ATTEND:

Name:

Location:

Number of Years Attended:

Are you a resident on Campus?  Yes  No  Do you Commute to Campus?  Yes  No
 

8. This FALL you will ENTER CLASSES as a:
Sophomore  Junior  Senior ** Student ID # **

9. I have received The Burnside Scholarship for the past number of year:
 

	2006/07	school year for	$1,000	$1,250
	2007/08	school year for	$1,750	$1,750
	2008/09	school year for	$2,000	$2,000
	2009/10	school year for	$2,000	$2,000

10. A COPY of GRADES for each semester in School must accompany this application.**

Include cost of last years Tuition and Fees: $
                                                           Books:  $
 
 
 
 
 
 
 
 
 
 
 
 
 
 

11. List any Leadership Activities, Special Academic or Service Awards for which you are especially proud. (Do Not include High School Activities)

 

List Current Employment:

Number of Hours per Week:

(If a program of studies doesn't allow enough time to work, please explain)

 

12. (3) References: (TWO) must be from the College that you attend.

Name:

Address:

Telephone Number:
 

Name:

Address:

Telephone Number:
 

Name:

Address:

Telephone Number:
 

13. Describe in 200 Words or Less Your Career/Life Goals and why you Are deserving of this Scholarship ( including family and financial circumstances, such as others in your family attending College). Have your goals changed during the past year and Why?

 
 
 
 
 
 
 
 
 
 
 
 
 

14. Provide a List of All Sources (including amounts) of Financial Assistance you have applied dor or currently receiving. ***A LETTER FROM YOUR COLLEGE OF YOUR FINANCIAL ASSISTANCE*** See Example Letter
 

I hereby certify that the information set forth in this application is true to the best of my knowledge. Further, I hereby give my permission for The Warren and Betty Burnside Foundation, Inc., or its designated representatives, to contact any financial Aid Officer, Guidance Counselor, or other advisor at any school in which I am enrolled, have been previously enrolled or to which I have made application for the purpose of soliciting and obtaining information which may be necessary or helpful to the Foundation in understanding my academic career and financial needs in connection with the processing of this application or for purposes of auditing the use of scholarship funds received as a result of application made to The Warren and Betty Burnside Foundation, Inc.

____________________________________       ________________________
(Signature)                                                               (Date)