Kiwanis Louisiana-Mississippi-West Tennessee District Foundation

2008-2009

LaMissTenn Circle K District

Scholarship Program

Sponsored by the Louisiana-Mississippi-West Tennessee Kiwanis District Foundation, Inc.

PURPOSE: The LaMissTenn Circle K District Scholarship Program, sponsored by the La.-Miss.-W.Tenn. Kiwanis District

Foundation, is designed to provide recognition and financial assistance to Circle K members who have excelled in their

collegiate careers. It is designed for Circle K'ers who have achieved academic excellence, demonstrated leadership

abilities and provided service to others. Financial need will not be a factor in this award.

QUALIFICATIONS: 1. The applicant must be a member of a Circle K Club within the La.-Miss.-W.Tenn. District, and be in good standing

with the home club, the district and Circle K International.

2. The applicant must have full-time student status during the current administrative year and be in good standing with

said enrolled college or university.

3. The applicant must have a grade point average equivalent of a 3.0 or better on a 4.0 scale.

APPLICATION REQUIREMENTS: (all information must be typewritten or computer-generated)

This 3-page application form must be fully completed and properly signed.

Two (2) passport photos that meet U.S. Passport regulations for possible publicity purposes. You can obtain these at a

FedEx-Kinko’s, Walgreen’s, Wal-Mart, or another similar retail store that offers passport photos.

One (1) letter of recommendation from a member of the Kiwanis Club that sponsors the applicant’s Circle K Club.

One (1) letter of recommendation from a member of the applicant’s Circle K Club.

A two-page (typed and double-spaced) essay answering the question:

"How has your involvement in Circle K made you more aware of the needs of other people?"

An official transcript.

A letter of verification concerning student status from the Dean of Students/School Registrar

The application, including all supporting documents requested, must be mailed to:

LaMissTenn CIRCLE K DISTRICT SCHOLARSHIP PROGRAM

P.O. Box 14026 * Baton Rouge, LA 70898-4026

NOTE: It is important to remember that this Official Application Form MUST be used for these scholarships in order to be

considered. Also, if all of the items requested above are not included, the applicant may not be considered for these

awards. Application materials become the property of the La.-Miss.-W.Tenn. District and will not be returned.

Deadline for submitting application package:

Postmarked by January 30, 2009

2008-2009 LaMissTenn Circle K District Scholarship Program (Please type all data)

PERSONAL DATA

NAME ____________________________________________________ S.S. # ______-_____-________

last first middle

MEMBER, CIRCLE K CLUB OF: _________________________________________________________

CURRENT ACADEMIC STATUS: Freshman SophomoreJunior Senior going directly to graduate school Graduate Student

CAMPUS ADDRESS: ____________________________________________________________________

street apt. number

____________________________________________________________________

city state zip code

HOME ADDRESS: ____________________________________________________________________

street apt. number

____________________________________________________________________

city state zip code

PHONE NUMBERS: (_____)________________ (_____)________________ (_____)________________

campus home mobile

UNDERGRADUATE ACADEMIC DATA

Major(s): _______________________________________________________________________________

Minor(s): _______________________________________________________________________________

In the School of__________________________________________ (e.g., business, liberal arts, fine arts, etc.)

Cumulative Grade Point Average: ___________________________________________________________

Undergraduate institution(s):

University or College: Dates: Major: Degree:

____________________________________ ____________ __________________ _______________

____________________________________ ____________ __________________ _______________

____________________________________ ____________ __________________ _______________

OFFICIAL APPLICATION FORM – Page 1 of 3

GRADUATE ACADEMIC DATA

Cumulative Grade Point Average:

Graduate Study:

University or College: Date Applied: Date Accepted: Field of Study:

_____________________________________ ______________ _____________ _________________

_____________________________________ ______________ _____________ _________________

_____________________________________ ______________ _____________ _________________

For what vocation will your course of study prepare you?

Career Goal/Expectations:

ACADEMIC PLANS

Institution attending for 2008-2009 academic year:

Mailing Address:

City: _______________________________________________ State: __________ Zip Code:

If no acceptance at this time, please check here:

CIRCLE K DATA

Date and Circle K Club joined:

Offices held and other Circle K involvement (include years served):

Check the percentage of the following that you attended or participated in during this past year:

1-24% 25-49% 50-74% 75-100%

Club Meetings

Club Service Projects

Club Fundraisers

Club Social Events

List District events you have attended (e.g., Fall Training Conferences, District Board Meetings, Rallies).

Include the years:

District Conventions attended (list by years):

International Conventions attended (list by years):

OFFICIAL APPLICATION FORM – Page 2 of 3

(List the years of involvement with each item) OTHER INFORMATION

Campus Activities/Offices:

Honoraries/Awards:

Community Activities:

Name of Hometown Newspaper:

Address: street city state zip code

Name and address of the President of the college/university where you earned/are earning your

undergraduate degree:

name title

address city state zip code

Name and address of the President of the college/university you wish to attend/are attending for your

graduate degree:

name title

address city state zip code

STATEMENT OF INTENTION I hereby state my intention to enroll in school and pursue my educational objectives in the Fall of the

2008-09 academic year.

Signature of Applicant: ______________________________________________ Date: ________________

CERTIFICATION I hereby certify that the application and supporting materials are correct to the best of my knowledge.

Signature of Applicant: ______________________________________________ Date: ________________

Signature of Circle K Club President: ___________________________________ Date: ________________

Signature of Faculty or Kiwanis Advisor: ________________________________ Date: ________________

Mail completed application by January 30, 2009, to:

LaMissTenn CIRCLE K DISTRICT SCHOLARSHIP PROGRAM

P.O. Box 14026, Baton Rouge, LA 70898-4026

OFFICIAL APPLICATION FORM – Page 3 of 3