grover duvall application 2012-2013

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Grover C. Duvall, Jr.Memorial Scholarship

Severna Park Elks~ BPOE 2482 ~

Application of Required Facts

Based On Americanism, Financial Need, Leadership & Scholarship

For the 2012 - 2013 academic year

2013 Scholarship Award: $1,200

Application must be filed with the Severna Park Elks Lodge by February 15, 2013.

Application must be endorsed when returned to Lodge for judging.Only a member of the Grover C. Duvall, Jr. ~ Severna Park Elks Membership/Legacy Scholarship Fund , the ExaltedRuler or the Lodge Secretary may endorse the application when returned to Severna Park Elks Lodge.

Signature of Endorser DateSeverna Park Elks Lodge Telephone Number: (410) 647-2482PO Box 982, Severna Park, MD 21146-1504


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Important: Before preparing this application, it is recommended that the proceduresoutlined on page 9 & 10 be carefully studied and then completelyexecuted.

Personal Information

Name: Social Security #Last First Middle Initial

Address: Phone: ( )Street City State Zip

Date of Birth: / / Place of Birth: Age: Sex:

Are you currently an American Citizen? (Resident Alien status does not qualify;applicant MUST be a citizen on the date the application is signed.)

Schools attended (ninth through twelfth grades)

Name of School Date of Entrance Period Attended



Date will Graduate: ,20 Number in Class: Rank in Class:


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Scholastic Activities

Honors and Awards (State nature of honor or award)

Offices and positions of Leadership (State name of organization, position andyear)

Member of organization where no office was held (Name of organization andyear Only major activities)

Note: Please list additional honors or activities on a separate sheet.


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School Related Extracurricular Activities






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Non-School Related Community Activities






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College Plans Financial Aid

State your plans for enrollment in an accredited US American college oruniversity along with your intended concentration of study:

Do you intend to apply for financial aid at the college(s) you plan to attend? Yes: No:

If so give details:

Have you reason to expect scholastic aid from any other source? Yes: No:

If so give details:

Applicant Employment History (Place of Employment, Position Held, Length of Employment,Hours per Week, etc.):


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Personal & Parental Financial Analysis

(Fill out following OR attach a copy of US Department of Education Student Aid Report [SAR]ORattach copy of parents prior year tax return[s])

Fathers/Stepfathers Name: Age: Occupation:

Mothers/Stepmothers Name: Age: Occupation:

Parents marital status - Mother: Married: Widowed: Divorced: Remarried:

Father: Married: Widowed: Divorced: Remarried:

*If you check Remarried, please include stepparents income in the appropriate section and read our instruction concerningcustodial parent.

Whenever the word parent (mother or father) is used, it also means step-parent

Father/Stepfathers 2012 annual income (earned from work) $

Mother/Stepmothers 2012 annual income (earned from work) $

Parent(s) adjusted gross income from 2012 (Bottom line first page of IRS 1040) $ (A)

** If you have not filed your tax return, you must estimate your adjusted gross income for 2012.

If applicable: Other person financially supporting your college education(i.e. stepparent; grandparent, etc) 2012 income (earned from work) $ (B)

If applicable: Other person financially supporting your college education(i.e. stepparent; grandparent, etc) 2012 income (earned from work) $ (C)

If applicable: Other person financially supporting your college education

(i.e. stepparent; grandparent, etc) 2012 income (earned from work) $ (D)

Other taxable income from parent(s) 2012 (IRS 1040 - all Schedules) $ (E)

All non-taxable income not included above ***(including pensions,IRA/Keogh, Social Security/disability benefits, child support, rent-free housing, etc.) $ (F)

***For Social Security only - Report benefits for parent(s), student and other siblings: Do not include benefits received bythe applicant.

GROSS (total of A through F) $(A+B+C+D+E+F)

Family

Family Size: include parent(s), student applicant, other dependent children and other familymembers if applicants parents are providing more than half their support:

Number of dependent children attending college during academic year 2012-2013 on a full timebasis (excluding the applicant)


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Additional Financial Information

Would you like to submit additional relevant financial information to explain the importance of this

scholarship? Is there other data to show financial need and general worthiness?

Endorsements

Signature of Student Date

Date: , 20 Signed By (Father/Stepfather)

Signed By (Mother/Stepmother)

Application must be endorsed when returned to Lodge for judging.Only a member of the Grover C. Duvall, Jr. Memorial Scholarship Fund, the Exalted Ruler or theLodge Secretary may endorse the application when returned to Severna Park Elks Lodge.

Signature of Endorser DateSeverna Park Elks Lodge Telephone Number: (410) 647-2482


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Severna Park Elks ~ BPOE 2482Grover C. Duvall, Jr. Memorial Scholarship

For students entering or returning to college for the fall semester of 2013. If the award winner fails to enrollin a university or college for the fall semester following the award presentation, the award will be absorbedinto the base principle of the scholarship fund.

This application must be filed with a Grover C. Duvall, Jr. Memorial Scholarship Fund Member, LodgeSecretary or Exalted Ruler of the Severna Park Elks, BPOE 2482. Only one application may be filed. The finaldate for filing the completed application with the Lodge is February 15, 2013.

All applicants must be citizens of the United States of America on the date the application is filed.

Americanism, financial need, leadership, community service, extracurricular activities and scholarship arethe criteria by which applicants will be judged.

Scholarship is subject to withdrawal if conduct of student is contrary to principles of the law and order andmorality supported by the Order of Elks.

Custodial Parent If your parents are divorced or separated, answer the questions for the parent you livedwith the most in the last 12 months. For example, if you lived with your mother more than your father, youwould count your mother. If you lived with your father instead of your mother, you would count yourfather. If you lived with both parent an equal number of days in the past 12-months, you would count theparent who provided you the greatest amount of support. Support would include material as well asfinancial help. Material things would include cars, clothing, medical and dental payment, etc. If that parenthas married or re-married you must include the stepparents information.

All scholarships are in the form of certificates of award issued by the Severna Park Elks, BPOE 2482,conditional upon the enrollment of the student in an accredited degree program in an accredited USAmerican college or university. Upon receipt of proof of enrollment, a Severna Park Elks, BPOE 2482 checkfor the amount of the award will be forwarded to the scholarship winner in the name of their college oruniversity.

The award winner will receive the certificate of award at the Severna Park Elks Installation of Officers

Dinner in March/April, 2013. The winner will be notified of the date and is expected to attend with theirparents, if possible. The cost of the dinner for the winner and their parents will be the responsibility of theSeverna Park Elks Lodge.

A student cannot accept more than one Grover C. Duvall, Jr. scholarship/grant in any one academic year.

A Social Security number is required for our records and if you do not have one, you should applyimmediately, at your nearest Post Office.

All applications become the property on the Grover C. Duvall, Jr. Memorial Scholarship Committee andSeverna Park Elks, BPOE 2482.

Grover C. Duvall Scholarships Committee Members

Bob Barnes, PER ~ ChairMabel Rupert ~ TreasurerNancy Hadad ~ Secretary

Mike Hadad, PERJackie Barnes, PERCleveland Duvall


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GENERAL INSTRUCTIONS

1. Applicant must use the official Severna Park Elks ~ BPOE 2482 Grover C. Duvall, Jr. MemorialScholarship form. It must be dated and signed by the student, Lodge official(s) and the parent(s) orguardian.

2. Applications and all supporting documents must be in English or English translations.3. Letters may be originals or photocopies on one side of a single sheet of 8 by11 paper signed by the

author.

4. Official high school transcript of student grades from the beginning of the 9th grade to due date ofapplication. May be photocopies that bear an original signature of the proper school authority.

5. SAT or ACT test scores must be included but may be photocopies. It is preferable that exhibits such asawards and media items be photocopies. Include only one (1) set of scores of either Sat or ACT scores.

6. Applications must be properly bound on left side with hinges or staples in a standard binder or cover.Elaborate bindings are discouraged. Clear plastic or bulky covers are undesirable.

7.

Counting the application as 8-pages, the completed brochure must not exceed 25-pages (one side only)

8. The application must be arranged in the order described below:a. Application of Required Facts. Carefully plan a response to each item before the final draft.

Use 1 for freshmen year of school and 2, 3 and 4 for subsequent years to identify appropriatescholastic, extra curricular and civic activities. Secure all required dates.

b. MUST INCLUDE: The applicant shall prepare a statement of one (1) page or less using anumber 10 Arial or Times New Roman Font. The statement will in the applicants opiniondefine Americanism and why it is important today. It will also contain the applicantscurrent and future commitment and demonstration of Americanism. This letter must besigned.

c. Official signed transcript of high school grades.d. College entrance test scores required (SAT or ACT) one (1) set only.e. Current dated, signed one-page letters of recommendation from at least one person, but not

totaling more than three, in authority, from high school(s) and/or college attended by theapplicant. Letter may cover the applicants ability, work habits, leadership, personality andintegrity. An emphasis on the applicants commitment to Americanism is encouraged.

f. Two letters of endorsement from responsible community (non-school) persons. These personsshould not be related to the applicant. They should be capable of reporting the applicantsparticipation in the community in terms of work service, leadership, notable skills andoutstanding recognition. An emphasis on the applicants commitment to Americanism isencouraged. Each letter should be typed, dated, signed and no more than one sided of an 8

X 11 page.

g. Copies of exhibits of achievement in scholarship, leadership, Americanism, athletics,dramatics, community service or other activities may be attached but avoid being repetitious.

Best Wishes & Good Luck!

grover duvall application 2012-2013

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