Marshall-Putnam Farm Bureau

Marshall-Putnam Farm Bureau Scholarship Application

All questions must be answered. Please type or print all your answers, and return the completed application no later than February 15, 2010 to one of the addresses listed below:

Rhonda Bangert	Marshall-Putnam Farm Bureau
Chair, M-P Farm Bureau Scholarship	M-P Farm Bureau Scholarship
117 S. Jefferson Street	509 Front Street
PO Box 340	PO Box 208
Washburn, IL 61570	Henry, IL 61537

Name of Applicant:
Address of Applicant:
Names of Parents or Guardians:

Address of Parents or Guardians:
Parents' or Guardians' Phone:	() -
Applicant Date of Birth:	/ / (mm/dd/yyyy)
Applicant Gender:	Male / Female
Any Farm Bureau Membership Start Date (You or Parent/Guardian):	/ (mm/yyyy)
Marshall-Putnam Farm Bureau Membership Start Date (You or Parent/Guardian):	/ (mm/yyyy)
Date of High School Graduation:	/ (mm/yyyy)
Names of High School:
Address of High School:
Date ACT Test Taken by Applicant:	/ / (mm/dd/yyyy)
College or University Planned to Attend:
State of College or University Planned to Attend:

I hereby certify that to the best of my knowledge the information given on this application is accurate; that I have read and understand the “Guidelines” which I received along with this application; and that I agree to abide by these guidelines and the decision of the Scholarship Committee. I further understand that, prior to receipt of my scholarship funds, at the beginning of each semester I must first submit evidence to the Scholarship Committee Chairman that I have (a) paid my registration fees, (b) enrolled for at lease 12 semester hours (c) for the second semester payment have maintained at least a C average by submitting a copy of my first semester grades.

Upon submission of this form, I accept this as an electronic signature of this application for the Marshall-Putnam Farm Bureau Scholarship.