APPLICATION – EXCELLENCE SCHOLARSHIP OF NORTHWEST ARKANSAS

Excellence Scholarship of NWA Application

Scholarship awarding $1000 per academic year for 2 years.

APPLICANT INFORMATION

Applicant's Name *

First

Middle

Last

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Applicant's Email *

FATHER’S INFORMATION

Name of Father/Stepfather/Guardian

Father's Employer

Father's Occupation

Address Line 1

Address Line 2

City

State

Zip Code

Phone

MOTHER’S INFORMATION

Name of Mother/Stepmother/Guardian

Mother's Employer

Mother's Occupation

Address Line 1

Address Line 2

City

State

Zip Code

Phone

OTHER FAMILY MEMBERS CURRENTLY ATTENDING COLLEGE

Family Member Attending College - Name

Family Member Attending College - Relationship

Family Member Attending College - College Attended

Family Member Attending College - Year in College

2nd - Family Member Attending College - Name

2nd - Family Member Attending College - Relationship

2nd - Family Member Attending College - College Attended

2nd - Family Member Attending College - Year in College

3rd - Family Member Attending College - Name

3rd - Family Member Attending College - Relationship

3rd - Family Member Attending College - College Attended

3rd - Family Member Attending College - Year in College

HIGH SCHOOL INFORMATION

Name of Your High School

Principal’s Name

Cumulative GPA

Current Grade (Junior/Senior)

Graduation Date

School Counselor’s Name

POST SECONDARY SCHOOL INFORMATION

Checkboxes

Plan Unknown

Name of post-secondary school you plan on attending

Type of post secondary school

4-yr. College/University
2-yr. Community College
Vocational/Technical School

Name of additional post-secondary school considered for attending

Type of additional post secondary school (copy)

4-yr. College/University
2-yr. Community College
Vocational/Technical School

WORK EXPERIENCE

Please list your paid work experience from the past four years, beginning with the most recent position.

Employer's Contact Name

Employer's Phone Number

Start Date - End Date

Job Duties

2nd - Employer's Contact Name

2nd - Employer's Phone Number

2nd - Start Date - End Date

Job Duties

3rd - Employer's Contact Name

3rd - Employer's Phone Number

3rd - Start Date - End Date

Job Duties

4th - Employer's Contact Name

4th - Employer's Phone Number

4th - Start Date - End Date

Job Duties

SCHOOL ACTIVITIES & PUBLIC SERVICE

Please list extracurricular activities and public service or volunteer work you have participated in during the past four years in order of importance to you.

Activity

No. of Years Participated

Positions & Awards, & Recognition

2nd - Activity

2nd - No. of Years Participated

2nd - Positions & Awards, & Recognition

3rd - Activity

3rd - No. of Years Participated

3rd - Positions & Awards, & Recognition

4th - Activity

4th - No. of Years Participated

4th - Positions & Awards, & Recognition

5th - Activity

5th - No. of Years Participated

5th - Positions & Awards, & Recognition

6th - Activity

6th - No. of Years Participated

6th - Positions & Awards, & Recognition

7th - Activity

7th - No. of Years Participated

7th - Positions & Awards, & Recognition

8th - Activity

8th - No. of Years Participated

8th - Positions & Awards, & Recognition

REFERENCES

Please list three non-relative references to contact on your behalf.

Reference Name / Phone

Reference Relationship

Reference No. of Years Known

2nd - Reference Name / Phone

2nd - Reference Relationship

2nd - Reference No. of Years Known

3rd - Reference Name / Phone

3rd - Reference Relationship

3rd - Reference No. of Years Known

QUESTIONS FOR APPLICANT

Anticipation of Use of Degree (i.e. employment type, further education)

What is the biggest obstacle you face in achieving this goal?

What is the most important issue facing our country, and why?

Are you currently facing a financial hardship concerning your academic career, or do you anticipate that you will during your academic career? If so, explain.

Are there any other factors about yourself that should be considered for this scholarship?

ADDITIONAL INFORMATION REQUESTED

Current High School Transcript

Copy of ACT/SAT/ COMPASS Scores - If applicable

CERTIFICATION

Yes, I hereby affirm that the information provided on this form is accurate and complete to the best of my knowledge. *

I hereby affirm that the information provided on this form is accurate and complete to the best of my knowledge.

DISCLAIMER - The Excellence Scholarship of NWA shall not discriminate against any applicant on the basis of any applicable protected classification including, but not limited to: race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in the selection of a scholarship recipient. Any related parties to board members or substantial contributors to The Reutzel Foundation, Inc. shall not be considered.

Name