INDIANA REGION NATIONAL COUNCIL OF CORVETTE CLUBS SCHOLARSHIP APPLICATION

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1 APPLICATION Fill out all items accurately and completely. Errors and omissions will delay processing. Completed application must be received by May 1, Please print or type. Return all forms to: Indiana Region NCCC Scholarship Committee US31 South Lakeville, IN FULL LEGAL NAME FIRST MIDDLE LAST DATE OF BIRTH / / MONTH DAY YEAR SOCIAL SECURITY NUMBER - - HOME ADDRESS NUMBER AND STREET CITY STATE ZIP HOME PHONE COUNTRY OF CITIZENSHIP STATE OF CLAIMED RESIDENCE PARENTS OR GUARDIANS FULL NAMES NUMBER AND STREET CITY STATE ZIP AFFILIATION WITH INDIANA REGION NCCC PROVIDE A BRIEF DESCRIPTION OF APPLICANT'S AND FAMILY'S INVOLVEMENT YOUR NCCC NUMBER CLUB AFFILIATION FATHER'S NCCC NUMBER CLUB AFFILIATION MOTHER'S NCCC NUMBER CLUB AFFILIATION OTHER RELATIVE NCCC NO CLUB AFFILIATION IDENTIFY OTHER RELATIVE

2 YOUR EDUCATION HIGH SCHOOL GRADUATION DATE HIGH SCHOOL FROM WHICH YOU WILL OR DID GRADUATE NAME OF INSTITUTION SAT/ACT DATES STREET ADDRESS SAT DATE PLACE TAKEN ACT DATE PLACE TAKEN HIGH SCHOOL EXTRA CURRICULAR ACTIVITIES HIGHER EDUCATION LIST ALL COLLEGES, UNIVERSITIES OR TECHNICAL SCHOOLS ATTENDED OR CURRENTLY ATTENDING INSTITUTION CITY AND STATE DATES GPA INSTITUTION WHICH HAS ACCEPTED YOU NAME OF INSTITUTION SIGNATURE I CERTIFY THAT THE INFORMATION PROVIDED ON THIS APPLICATION IS ACCURATE AND TRUE. I UNDERSTAND THAT FALSIFIED INFORMATION MAY RESULT IN DENIAL OF INDIANA REGION NCCC BENEFITS. Applicant's signature Date

3 NCCC APPLICATION Applicant's signature Date TO BE COMPLETED BY HIGH SCHOOL GUIDANCE COUNSELOR. ALL APPLICANTS MUST HAVE THIS SECTION COMPLETED. HIGH SCHOOL CLASS RANKING AFTER SEMESTERS PLEASE INDICATE IF SCHOOL DOES NOT RANK STUDENTS. GRADE POINT AVERAGE / G.P.A. SCALE TEST SCORES SAT: DATE V M DATE V M PSAT: DATE V M ACT: DATE E M R SR C DATE E M R SR C PACT: DATE E M R SR C COMMENT INFORMATION RELATIVE TO AN ADMISSIONS DECISION IS REQUESTED PLEASE INCLUDE A TRANSCRIPT OF HIGH SCHOOL WORK THROUGH THE JUNIOR YEAR NARRATIVE EVALUATION: WE APPRECIATE THE DIFFICULTY OF EVALUATING A STUDENT ON THE BASIS OF RANKING ON A GRID. PLEASE USE THIS SPACE FOR NARRATIVE EVALUATION. WE ARE ESPECIALLY INTERESTED IN THE INTANGIBLE QUALITIES WHICH OFTEN CONTRIBUTE TO ACADEMIC SUCCESS. A LETTER MAY BE ATTACHED IF PREFERRED. SIGNATURE SIGNATURE OF COUNSELOR PRINTED NAME DATE Return all forms to: Indiana Region NCCC Scholarship Committee, US31 South, Lakeville, IN 46536

4 ESSAY WRITE A 300 WORD ESSAY, IN YOUR OWN HANDWRITING AND ON THIS SHEET, OUTLINING YOUR REASONS FOR APPLYING FOR THIS AND YOUR CAREER GOALS Return all forms to: Indiana Region NCCC Scholarship Committee, US31 South, Lakeville, IN 46536

5 RULES AND REQUIREMENTS OF THE The Indiana Region NCCC scholarship will be given for the purpose of assisting a person with an Indiana Region NCCC affiliation in the continuation of his/her formal education. Any continuing education program is acceptable; any school or college having any curriculum. Some preference may be given to recent graduates and high school seniors. The award will be for one year. Previous winners are eligible. No financial need requirement is to be established. THE APPLICANT The applicant for the Indiana Region Scholarship must meet the following requirements: (1) a close personal involvement either as an NCCC member or a legal member of the immediate family of an Indiana Region NCCC member. (2) a high school diploma or the anticipation of a high school diploma before the time that the scholarship is to be awarded. A copy of the diploma must be provided before an award can be presented. (3) an academic standing in the upper half of the high school graduating class. (4) a record of involvement in some extra curricular activities in high school. (5) must be able to furnish a letter of acceptance from the institution for which the scholarship is to be awarded. (6) a brief 300 word essay, included with the application, outlining the reasons for wanting the scholarship and outlining the applicant's career goals. (7) three letters of recommendation from persons who are qualified to evaluate the applicant's potential. The enclosed form is to be used when asking for the recommendations. The high school information must be included. If the applicant is currently enrolled in a higher education program, please include a transcript for most recent academic year completed. (8) Applicant must think Corvettes are cool. (9) The completed application must be received by May 1, 2016 in order to be considered. The applicant will be responsible for submitting all required items before May 1, Be sure to provide addressed and stamped envelopes for the people you are asking to give evaluations and recommendations. The Indiana Region will not ask for this award to be repaid. Should the recipient find it appropriate, a contribution in the future to the Indiana Region NCCC for a scholarship fund would be appreciated.

6 RECOMMENDATION FOR TO THE APPLICANT: Please complete the top section of this form. Full Legal Name last first middle Present Address number and street city state zip Applicant's signature Date Send this recommendation to: Indiana Region Scholarship Committee, US31 South, Lakeville, IN TO THE PERSON PROVIDING THIS RECOMMENDATION: PLEASE COMPLETE THIS SECTION AND MAIL TO THE ABOVE ADDRESS. I have known the applicant for years in my capacity as 1. Please rate the applicant on each characteristic in comparison with other students at the same level by circling the appropriate number No Basis For Below Above Judgment Weak Average Average Average Exceptional A. Motivation B. Intellectual Ability C. Breadth of General Knowledge D. Understanding of Major Field E. Ability to Analyze Ideas F. Ethical Standards and Integrity G. Oral English and Expression Skills H. Written English Expression Skills I. Potential for Success J. Promise in Scholarship/Creative Endeavor K. Overall, I expect the applicant's work to be: On a separate page that you attach to this form, please provide your candid assessment of the applicant's strengths and weaknesses. In your opinion, does the applicant possess the intellectual and personal qualifications necessary for success? Respondent's Signature Date Telephone Number Type or Print Name Title or Position Institution or Affiliation Address

7 RECOMMENDATION FOR TO THE APPLICANT: Please complete the top section of this form. Full Legal Name last first middle Present Address number and street city state zip Applicant's signature Date Send this recommendation to: Indiana Region Scholarship Committee, US31 South, Lakeville, IN TO THE PERSON PROVIDING THIS RECOMMENDATION: PLEASE COMPLETE THIS SECTION AND MAIL TO THE ABOVE ADDRESS. I have known the applicant for years in my capacity as 1. Please rate the applicant on each characteristic in comparison with other students at the same level by circling the appropriate number No Basis For Below Above Judgment Weak Average Average Average Exceptional A. Motivation B. Intellectual Ability C. Breadth of General Knowledge D. Understanding of Major Field E. Ability to Analyze Ideas F. Ethical Standards and Integrity G. Oral English and Expression Skills H. Written English Expression Skills I. Potential for Success J. Promise in Scholarship/Creative Endeavor K. Overall, I expect the applicant's work to be: On a separate page that you attach to this form, please provide your candid assessment of the applicant's strengths and weaknesses. In your opinion, does the applicant possess the intellectual and personal qualifications necessary for success? Respondent's Signature Date Telephone Number Type or Print Name Title or Position Institution or Affiliation Address

8 RECOMMENDATION FOR TO THE APPLICANT: Please complete the top section of this form. Full Legal Name last first middle Present Address number and street city state zip Applicant's signature Date Send this recommendation to: Indiana Region Scholarship Committee, US31 South, Lakeville, IN TO THE PERSON PROVIDING THIS RECOMMENDATION: PLEASE COMPLETE THIS SECTION AND MAIL TO THE ABOVE ADDRESS. I have known the applicant for years in my capacity as 1. Please rate the applicant on each characteristic in comparison with other students at the same level by circling the appropriate number No Basis For Below Above Judgment Weak Average Average Average Exceptional A. Motivation B. Intellectual Ability C. Breadth of General Knowledge D. Understanding of Major Field E. Ability to Analyze Ideas F. Ethical Standards and Integrity G. Oral English and Expression Skills H. Written English Expression Skills I. Potential for Success J. Promise in Scholarship/Creative Endeavor K. Overall, I expect the applicant's work to be: On a separate page that you attach to this form, please provide your candid assessment of the applicant's strengths and weaknesses. In your opinion, does the applicant possess the intellectual and personal qualifications necessary for success? Respondent's Signature Date Telephone Number Type or Print Name Title or Position Institution or Affiliation Address

9 RECOMMENDATION FOR TO THE APPLICANT: Please complete the top section of this form. Full Legal Name last first middle Present Address number and street city state zip Applicant's signature Date Send this recommendation to: Indiana Region Scholarship Committee, US31 South, Lakeville, IN TO THE PERSON PROVIDING THIS RECOMMENDATION: PLEASE COMPLETE THIS SECTION AND MAIL TO THE ABOVE ADDRESS. I have known the applicant for years in my capacity as 1. Please rate the applicant on each characteristic in comparison with other students at the same level by circling the appropriate number No Basis For Below Above Judgment Weak Average Average Average Exceptional A. Motivation B. Intellectual Ability C. Breadth of General Knowledge D. Understanding of Major Field E. Ability to Analyze Ideas F. Ethical Standards and Integrity G. Oral English and Expression Skills H. Written English Expression Skills I. Potential for Success J. Promise in Scholarship/Creative Endeavor K. Overall, I expect the applicant's work to be: On a separate page that you attach to this form, please provide your candid assessment of the applicant's strengths and weaknesses. In your opinion, does the applicant possess the intellectual and personal qualifications necessary for success? Respondent's Signature Date Telephone Number Type or Print Name Title or Position Institution or Affiliation Address

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