Marshall-Putnam Farm Bureau Scholarship Application

December 13, 2010

All questions on the application must be answered and submitted no later than February 17, 2011.

Name of applicant

Last Name: *

First Name: *

Middle Name: *

Address of applicant: *

Names of parents or guardian: *

Address of parents or guardian: *

Phone: *

Date of birth: *

Sex: *

Male

Female

From what date have you or your parent or guardian been a member of the Farm Bureau® somewhere in the state of Illinois?

Month: *

Year: *

From what date have you or your parent or guardian been a member of the Marshall-Putnam Farm Bureau®?

Month: *

Year: *

From what date have you been a resident of Marshall or Putnam counties?

Month: *

Year: *

Projected date of your High School graduation?

Month: *

Year: *

Name and address of High School : *

Where did you take your ACT Test? : *

What date did you take your ACT Test? : *

What college do you plan to attend next year? : *

City and State where located: *

Certification: *

Yes

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 "Scholarship Guidelines"; 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 least 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.

Date: *