Personal Information
Name (First, Middle, Last)
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Telephone Number
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Home Address
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Email Address
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City, State, Zip
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County
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Length of residence in this county (years)
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Name of Parent or Guardian
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Address
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City, State, Zip
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Date and Place of Birth
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Is anyone dependent on you for support?
Choose One
Yes
No
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If yes, name and relationship
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How many family members will be attending college full-time during the next four years?
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Please list their names, relationship and years they will be attending college:
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College Information
Name of college you are planning to attend
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Location of College
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Anticipated cost of the first year's tuition, room & board and books
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Financial Need Information
Check any of the applicable items below to indicate how you plan to pay your expenses not covered by the scholarship
Money furnished by family
Earnings during the summer
Student Employment
Student Loans
Other means
Please list other means
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Are you aware of other monetary awards you are receiving?
Choose One
Yes
No
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High School Activities and Community Activities
Please list below activities in which you have participated during your high school career. (include high school activities and community activities)
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Special Awards and Honors
Please list below any special honors or awards received in high school or in the community while in high school.
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Essay
Please write below a short essay describing your career plans
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What has your experience over the last four years in Pittsfield High School band and/or chorus meant to you? How has it helped you grow and mature into a young adult?
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Transcript
Please upload High School transcript or have guidance office send transcript to trust@farmersstate.com (PDF files please)
File is required
Acknowledgment
I certify that, to the best of my knowledge, all information given on this application is true and correct.
Date
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Signature (please type name)
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