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Scholarship Application

First name*

Last name*

Email*

Phone*

Address*

Birthday

Are you an employee of Highway Safety Services?*

Yes

No

Are you a U.S Citizen?

Yes

No

Currently enrolled?*

High School

College/University/Tech School?

If you are enrolled, please let us know the name of your school and program.

EDUCATION

Highschool Name*

Dates of enrollment

Did you graduate?*

Yes

No

College Name*

Dates of Enrollment

Did you graduate?*

Yes

No

Other Education Institutions

Dates of Enrollment

Did you graduate?

Yes

No

REFERENCES

Please list three references we can contact

Reference 1 name

Country/Region

Address

City

Zip / Postal code

Phone

Reference 2 name

Country/Region

Address

City

Zip / Postal code

Phone

Reference 3 name

Country/Region

Address

City

Zip / Postal code

Phone

EMPLOYMENT

Company name*

Address

Position

Supervisor Name*

Phone

Company Name

Address

Position

Supervisor Name

Phone

MILITARY SERVICE

Branch of service

Dates of service

Rank at discharge

Type of discharge

If other then honorable, please explain:

DISCLAIMER AND SIGNATURE

I certify that my answers are true and complete to the best of my knowledge.

Signature*

Date

STATEMENT OF PURPOSE

(Tell us why you are applying and your goals for pursuing higher education)

Statement of Purpose

List any academic award you have received.

List your hobbies, outside interests, extracurricular activities, volunteer activities:

Career plans and Field of study that you are interested in and wish to pursue:

Tell us why you deserve this scholarship:

Tell about your leadership experience: 'Great leaders don’t set out to be a leader...they set out to make a difference. It’s never about the role-always about the goal.'

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