Brevard Federated Republican Women Scholarship Application

PLEASE PRINT APPLICATION, FILL OUT AND EMAIL TO DIXIE RIEPL AT DRIEPL6871@GMAIL.COM

APPLICANT INFORMATION

Name:

Scholarship applying for:

Date of birth: SSN:

Phone:

Current address:

City: State:

ZIP Code:

Are you a US Citizen?

Email

University Name and

Address 

City State Zip 

High School Information 

Name of High School

Address

City State FL

Zip

Date Graduated Grade Point Average

High School Activities and Achievements

High School Reference name

and contact info

UNDERGRADUATE STUDY

Name of University

Address:

Phone:

E-mail:

Fax:

City:

State:

ZIP Code:

Major (s)

Minor (s)

Expected Graduate date:

Grade point average

COLLEGIATE ACTIVITIES AND ACHIEVEMENTS INCLUDING CIVIC AND POLITICAL ACTIVITIES AND INTERESTS

Are you registered to vote

Did you vote in the last

election

If either answer is no please explain

What political activities have you participated in, and how were you involved

List any work or volunteer experience

What are your hobbies and interests

I verify that the information in this application is true and accurate to the beset of my knowledge

Signature of applicant

Date

Signature of co-applicant, if for joint account

Date