1. NAME: Last, First, Middle

2. HOME ADDRESS:

Street:

City: State: Zip Code:

County:

Telephone Number: (304)

3. Date of Birth: / /19 Social Security # - -

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

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

Father: Employer:

Mother: Employers:

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 +
 
 
 

6. Name of High School that you attend.

7. Name of College or School you will attend this fall:

8. A COPY OF THE FOLLOWING MUST BE ATTACHED TO THIS APPLICATION:

**AMERICAN COLLEGE TEST (ACT), SCHOLASTIC APTITUDE TEST (SAT) and TRANSCRIPT OF GRADES**
 

9. In the Space Below List your most important activities School, Church and Community including any Offices Held, Awards Received or Special Recognition.

11. (3) References: (TWO) should be from the school that you attend

Name:

Address:

Telephone Number:
 
 

Name:

Address:

Telephone Number:
 
 

Name:

Address:

Telephone Number:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

12. Please Describe in 200 Words or Less Your Career/Life Goals and Why you Are Deserving of this Scholarship ( including family and financial circumstances and list others in your family attending college).   What you consider significant achievements in your life:

13. Provide a List of All Sources (including amounts) of Financial Assistance you are currently receiving or anticipate receiving:
 

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)