First Name:       
Last Name:       
Street Address  
City:        Winston-Salem Advance Cary Chapel Hill Clemmons Durham Fuquay-Varina Garner Germanton Greensboro Kernersville King Lewisville Lexington Morrisville Pfafftown Raleigh Rural Hall Walkertown Yadkinville     State:       Choose a State North Carolina Outside US / Canada Alabama Alaska Alberta American Samoa Arizona Arkansas Armed Forces Americas Armed Forces Europe Armed Forces Pacific British Columbia California Colorado Connecticut Delaware District Of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota Northern Mariana Is Northwest Territories Nova Scotia Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Province du Quebec Puerto Rico Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Yukon Territory    Zip:  

E-mail:   

Phone (h)   

Phone (w)   

At what skills would you like to see this student improve?

Financial Statement

Occupation:

Employed By:

If not employed, please explain

Estimated annual family income from all sources (salaries, wages, interest, pensions, social security, welfare, etc)

Select one:  Family Income Under $25,000 $25,000-35,000 $35,000-45000 $45,000-55,000 Over $55,000

Income tax (Federal) paid last year (approximate)

Number of dependant children

Amount of scholarship requested (please request what you need) Select Amount $50 $75 $100 $125 $150 $200

Please provide any comments that may help us understand your financial circumstance.

Certification

To the best of my knowledge the above information is complete and correct.

On "Submit", you will see the results of the form you filled out. If there are any errors, use the your browser's "Back" button to return to this page and resubmit the application without having to reenter all of the information.