Instructions:
1. Fill out this form and limit responses to the area shown (Do not scroll within the boxes.)
2. "Print" a copy for your records.
3. Click on the "Submit" button to complete the application process and submit this form.
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Name -
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Address -
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College planning to attend -
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County -
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Home Telephone No. -
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E-Mail Address -
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Name of Parent(s) or Guardian -
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Parent(s) Occupation/Employment
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Father's Occupation -
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Telephone (Daytime) -
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Mother's Occupation -
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Telephone (Daytime) -
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Section A - Academic Information
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1. Name and Address of High School
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2. Name and Address of Community College
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Year of High School Graduation -
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Year of Community College Graduation -
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3. National testing Scores
SAT - -
Verbal Math
Date tested -
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ACT -
Date tested -
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4. Cumulative High School GPA -
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Cumulative Community College GPA
Semester Hours Completed -
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5. List Awards and/or achievements during your last TWO YEARS of high school and/or community college career
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6. Field in which you plan to major
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7. Describe why you are interested in pursuing a college education and include why you chose this field
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Section B - Financial Information
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1. Explain your need for financial assistance. Describe how you would use this scholarship in your financial planning
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2. Total Parental income from 2010 federal tax return
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3. Will you have any brothers or sisters attending college during the next year?
Yes
No
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If Yes, Explain
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4. Will you be receiving or will you be a candidate for any other scholarship to attend college?
Yes
No
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If Yes, Explain
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5. List any part-time jobs previously held
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Statement by Applicant
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I personally have prepared this report and certify that it accurately reflects my work. I further certify that I will be a graduating senior in high school during 2011, and I will be an entering freshman at an accredited university or community college in Mississippi or I will be transferring from a community college to an accredited university in Mississippi.
Name of applicant -
Date -
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Approval of this Report
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I have reviewed this report and believe it to be correct
Name of Parent/Guardian -
Date -
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Please print a copy for your records before submitting.
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If you have questions, contact:
Gary Blair, Chairman
Scholarship Committee, MCC
Phone: (601) 833 1771
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