Date:

Name:

University E-mail:

Student ID #:

Permanent Address:

City, State, Zip:

Home Telephone #:

Work Telephone #:

Year in School:

Major:

Cumulative GPA:

Educational Background:

High School Attended: (Name, Address, Dates)

University Attendance: (Name, Address, Dates)

List activities in which you have participated or other ways in which you may have been of service. (High School, College, Church and Community---include honors, awards, scholarships and/or positions of leadership)

List name and address of an instructor or other professional person in Eau Claire or your home community who could be used as a personal reference.

Name:

Title:

Address:

City, State, Zip:

Home Telephone #:

Work Telephone #:

Please write a one-page essay describing how this scholarship will be of assistance to you in continuing your education.