Completed applications must be postmarked by April 1^st to the attention of the Scholarship Committee.

(Copy & paste desired sections to word & print)

Mt Hermon Lodge No. 263

P.O. Box 1514

Cedar Rapids, Iowa 52406

Official Application for Scholarship

Date: _____________

1. Name _______________________________________________________________
First Middle Last

2. Date of Birth ______________ Social Security # ______ ____ ________

3. Permanent Address ____________________________________________
Street or PO Box

______________________________ ______________________ _______________
City State Zip Code

________________________
Telephone with Area Code

4. Names of Parents/Guardian

Name ______________________________________ Relationship __________________

Address ____________________________________________
Street or PO Box

______________________________ ______________________ _______________
City State Zip Code

_______________________
Telephone with Area Code

(If not living with parents, give name, address and relationship of person with whom you live.)

5. Name, address and relationship of person this application is based on who is a member of

Mt. Hermon Lodge No. 263.

Name ______________________________________ Relationship __________________

Address ____________________________________________
Street or PO Box

______________________________ ______________________ _______________
City State Zip Code

________________________
Telephone with Area Code

6. Applicant’s High School _________________________________________________

Address ____________________________________________
Street or PO Box

______________________________ ______________________ _______________
City State Zip Code

________________________
Telephone with Area Code

7. Graduation Date _________________

8. Grade Point Average _________ Rank in Class ________ Number in Class ______

ACT Score _________ (If available) SAT Score_________ (If available)

Attach photocopies if available.

9. Attach current certified transcript of your academic record.

10. Name and location of school where you wish to enroll

School __________________________________________________________________

Location _______________________________________________________________
City State

11. Anticipated major ____________________________________________________

12. What have you done in the way of self-support?

13. Need for Financial Assistance. Indicate how you plan to finance your post-secondary education. If you desire, relate any special circumstances that have a direct bearing on your need for financial assistance.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
14. School Activities. List both scholastic and extra curricular school related activities stating name of activity/organization and years involved (i.e. Band 9,10,11,12). List positions of leadership held and year. List honors and awards; include year and nature of honor or award.

Scholastic __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Extra-Curricular

15. Extra-Curricular Activities (non-school related). State name of activity/organization and years involved. List positions of leadership held and year. List honors and awards; include year and nature of honor or award.

16. Community Service. Describe the ways in which you, as a volunteer, have been of service to your community in general and/or to certain people in you community in particular. This service may have been performed as a member of an organization and/or on your own as an individual. Indicate leadership roles you may have had in this area. Describe any special circumstances, which may have limited your participation in community service.

17. Personal Resume in your own hand writing. Write about yourself, your home, family, interests and educational or vocational goals in a way, which will give the Committee the best picture of you as an individual. Do not include information requested in other sections of this application.

18. I have requested letters of recommendation from the following individuals:

Principal or Counselor _____________________________________________________
                                                       Name                                                       Position
Address ____________________________________________
                                       Street or PO Box
______________________________    ______________________ _______________
                  City                                                      State                            Zip Code

________________________
Telephone with Area Code

Business/Professional Person, Teacher, Civic or Organizational Leader

_______________________________________________________________________
Name Position

Address ____________________________________________
Street or PO Box

______________________________ ______________________ _______________
City State Zip Code

________________________
Telephone with Area Code

Member of the Clergy

___________________________________________________________________
Name Position

Affiliation _______________________________________________________________

Address ____________________________________________
Street or PO Box

______________________________ ______________________ _______________
City State Zip Code

________________________
Telephone with Area Code

19. Additional pages of narrative or supporting documentation may be added to any section. This can include newspaper clippings, photographs and other materials that will give the Committee a better insight about you, your school and community activities. Submit materials that you do not expect to be returned.

20. It is the responsibility of the applicant to fully and truthfully answer all questions, and to submit all requested materials. Without this material, this application may not be considered.

________________ __________________________________________
Date Applicant Signature

__________________________________________
Print Name

To the best of my knowledge, the applicant is able to enter and complete his/her course of study.

__________________ __________________________________________
Date Parent/Guardian Signature

The Mt. Hermon Scholarship Committee must receive completed application by April 1^st.

Attach current certified transcript, and ACT and/or SAT scores if available.

Letters of recommendation must be submitted to the Committee by April 15^th.

Mail to:

Scholarship Committee

Mt Hermon Lodge No. 263

P.O. Box 1514

Cedar Rapids, IA 52406

---------------------------------------------------------------------------------------------------------------------

(For Committee use only)

Approved by Mt. Hermon Lodge No. 263 Scholarship Committee

__________________ ____________________________________
Date Chairman

_________________________________ ____________________________________
Committee member Committee member

Submit letter by April 15th Mail to:

Scholarship Committee

Mt Hermon Lodge No. 263

P.O. Box 1514

Cedar Rapids, IA 52406

To the Principal or Counselor,

__________________________________________ of your High School is applying for a scholarship to be presented by Mt. Hermon Lodge No. 263, of Cedar Rapids, Iowa. These scholarships are for the purpose of assisting deserving young people attain higher education. Will you please help us determine whether the above named individual should be awarded a scholarship? All statements you make will be regarded as strictly confidential.

Thank you,

Mt Hermon Scholarship Committee

A. Attest to standards of conduct, strength of character, adherence to truth and conscience, and devotion to academics.

B. Describe involvement in activities at school, and other organizations.

C. Applicants ability to complete planned course of study.

D. Basis of financial need if known.

Submit letter by April 15th Mail to:

Scholarship Committee

Mt Hermon Lodge No. 263

P.O. Box 1514

Cedar Rapids, IA 52406

Dear Business/Professional Person, Teacher, Civic or Organizational Leader,

__________________________________________ is applying for a scholarship to be presented by Mt. Hermon Lodge No. 263, of Cedar Rapids, Iowa. These scholarships are for the purpose of assisting deserving young people attain higher education. Will you please help us determine whether the above named individual should be awarded a scholarship? All statements you make will be regarded as strictly confidential.

Thank you,

Mt Hermon Scholarship Committee

A. Attest to standards of conduct, strength of character, adherence to truth and conscience, and devotion to community.

B. Describe involvement in activities of volunteerism, community involvement and other organizations.

C. Applicants ability to complete planned course of study.

D. Basis of financial need if known.

Submit letter by April 15th

Mail to:

Scholarship Committee

Mt Hermon Lodge No. 263

P.O. Box 1514

Cedar Rapids, IA 52406

Dear Member of the Clergy,

Thank you,

Mt Hermon Scholarship Committee

A. Attest to standards of conduct, strength of character, adherence to truth and conscience, and devotion to church.

B. Describe involvement in activities of church.

C. Applicants ability to complete planned course of study.

D. Basis of financial need if known.

Return to Scholarship Award Page