Grover C. Duvall, Jr. Memorial Scholarship

Severna Park Elks

~ BPOE 2482 ~

Application of Required Facts

Based On Americanism, Financial Need, Leadership & Scholarship

For the 2011 - 2012 academic year

2012 Scholarship Award: $1,200

Application must be filed with the Severna Park Elks Lodge by February 15, 2012.

Application must be endorsed when returned to Lodge for judging.

Only a member of the Grover C. Duvall, Jr. ~ Severna Park Elks Membership/Legacy Scholarship Fund, the Exalted Ruler or the Lodge Secretary may endorse the application when returned to Severna Park Elks Lodge.

Signature of Endorser Date Severna Park Elks Lodge Telephone Number: (410) 647-2482 PO Box 982, Severna Park, MD 21146-1504

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Important: Before preparing this application, it is recommended that the procedures outlined on page 9 & 10 be carefully studied and then completely executed.

Personal Information Name: Social Security # Last First Middle Initial

Address: Phone: ( ) Street City State Zip

Date of Birth: / / Place of Birth: Age: Sex: Are you currently an American Citizen? (Resident Alien status does not qualify; applicant MUST be a citizen on the date the application is signed.) Schools attended (ninth through twelfth grades) Name of School Date of Entrance Period Attended

Name of School Date of Entrance Period Attended

Name of School Date of Entrance Period Attended Date will Graduate: ,20 Number in Class: Rank in Class:

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Scholastic Activities

Honors and Awards (State nature of honor or award)

Offices and positions of Leadership (State name of organization, position and year)

Member of organization where no office was held (Name of organization and year – Only major activities)

Note: Please list additional honors or activities on a separate sheet.

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School Related Extracurricular Activities

Honors and Awards (State nature of honor or award)

Offices and positions of Leadership (State name of organization, position and year)

Member of organization where no office was held (Name of organization and year – Only major activities)

Note: Please list additional honors or activities on a separate sheet.

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Non-School Related Community Activities

Honors and Awards (State nature of honor or award)

Offices and positions of Leadership (State name of organization, position and year)

Member of organization where no office was held (Name of organization and year – Only major activities)

Note: Please list additional honors or activities on a separate sheet.

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College Plans – Financial Aid

State your plans for enrollment in an accredited US American college or university along with your intended concentration of study: Do you intend to apply for financial aid at the college(s) you plan to attend? Yes: No: If so give details:

Have you reason to expect scholastic aid from any other source? Yes: No: If so give details:

Applicant Employment History (Place of Employment, Position Held, Length of Employment, Hours per Week, etc.):

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Personal & Parental Financial Analysis

(Fill out following OR attach a copy of US Department of Education Student Aid Report [SAR] OR attach copy of parent’s prior year tax return[s])

Father’s/Stepfather’s Name: Age: Occupation: Mother’s/Stepmother’s Name: Age: Occupation: Parent’s marital status - Mother: Married: Widowed: Divorced: Remarried:

Father: Married: Widowed: Divorced: Remarried:

*If you check Remarried, please include stepparent’s income in the appropriate section and read our instruction concerning custodial parent.

Whenever the word “parent” (mother or father) is used, it also means “step-parent”

Father/Stepfather’s 2011 annual income (earned from work) $ Mother/Stepmother’s 2011 annual income (earned from work) $ Parent(s) adjusted gross income from 2011 (Bottom line first page of IRS 1040) $ (A)

** If you have not filed your tax return, you must estimate your adjusted gross income for 2011.

If applicable: Other person financially supporting your college education (i.e. stepparent; grandparent, etc) 2011 income (earned from work) $ (B) If applicable: Other person financially supporting your college education (i.e. stepparent; grandparent, etc) 2011 income (earned from work) $ (C) If applicable: Other person financially supporting your college education (i.e. stepparent; grandparent, etc) 2011 income (earned from work) $ (D) Other taxable income from parent(s) 2011 (IRS 1040 - all Schedules) $ (E) All non-taxable income not included above ***(including pensions,

IRA/Keogh, Social Security/disability benefits, child support, rent-free housing, etc.) $ (F)

***For Social Security only - Report benefits for parent(s), student and other siblings: Do not include benefits received by

the applicant.

GROSS (total of A through F) $ (A+B+C+D+E+F)

Family Family Size: include parent(s), student applicant, other dependent children and other family members if applicant’s parents are providing more than half their support:

Number of dependent children attending college during academic year 2011-2012 on a full time basis (excluding the applicant)

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Additional Financial Information

Would you like to submit additional relevant financial information to explain the importance of this

scholarship? Is there other data to show financial need and general worthiness?

Endorsements Signature of Student Date Date: , 20 Signed By (Father/Stepfather) Signed By (Mother/Stepmother)

Application must be endorsed when returned to Lodge for judging. Only a member of the Grover C. Duvall, Jr. Memorial Scholarship Fund, the Exalted Ruler or the Lodge Secretary may endorse the application when returned to Severna Park Elks Lodge. Signature of Endorser Date Severna Park Elks Lodge Telephone Number: (410) 647-2482

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Severna Park Elks ~ BPOE 2482 Grover C. Duvall, Jr. Memorial Scholarship

For students entering or returning to college for the fall semester of 2012. If the award winner fails to enroll in a university or college for the fall semester following the award presentation, the award will be absorbed into the base principle of the scholarship fund. This application must be filed with a Grover C. Duvall, Jr. Memorial Scholarship Fund Member, Lodge Secretary or Exalted Ruler of the Severna Park Elks, BPOE 2482. Only one application may be filed. The final date for filing the completed application with the Lodge is February 15, 2012. All applicants must be citizens of the United States of America on the date the application is filed. Americanism, financial need, leadership, community service, extracurricular activities and scholarship are the criteria by which applicants will be judged. Scholarship is subject to withdrawal if conduct of student is contrary to principles of the law and order and morality supported by the Order of Elks. Custodial Parent – If your parents are divorced or separated, answer the questions for the parent you lived with the most in the last 12 months. For example, if you lived with your mother more than your father, you would count your mother. If you lived with your father instead of your mother, you would count your father. If you lived with both parent an equal number of days in the past 12-months, you would count the parent who provided you the greatest amount of support. Support would include material as well as financial help. Material things would include cars, clothing, medical and dental payment, etc. If that parent has married or re-married you must include the stepparent’s information. All scholarships are in the form of certificates of award issued by the Severna Park Elks, BPOE 2482, conditional upon the enrollment of the student in an accredited degree program in an accredited US American college or university. Upon receipt of proof of enrollment, a Severna Park Elks, BPOE 2482 check for the amount of the award will be forwarded to the scholarship winner in the name of their college or university. The award winner will receive the certificate of award at the Severna Park Elks Installation of Officers Dinner in March/April, 2012. The winner will be notified of the date and is expected to attend with their parents, if possible. The cost of the dinner for the winner and their parents will be the responsibility of the Severna Park Elks Lodge. A student cannot accept more than one Grover C. Duvall, Jr. scholarship/grant in any one academic year. A Social Security number is required for our records and if you do not have one, you should apply immediately, at your nearest Post Office. All applications become the property on the Grover C. Duvall, Jr. Memorial Scholarship Committee and Severna Park Elks, BPOE 2482.

Grover C. Duvall Scholarships Committee Members

Bob Barnes, PER ~ Chair Mabel Rupert ~ Treasurer Nancy Hadad ~ Secretary

Mike Hadad, PER Jackie Barnes, PER Cleveland Duvall

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GENERAL INSTRUCTIONS

1. Applicant must use the official Severna Park Elks ~ BPOE 2482 Grover C. Duvall, Jr. Memorial Scholarship form. It must be dated and signed by the student, Lodge official(s) and the parent(s) or guardian.

2. Applications and all supporting documents must be in English or English translations. 3. Letters may be originals or photocopies on one side of a single sheet of 8 ½” by 11” paper signed by the

author. 4. Official high school transcript of student grades from the beginning of the 9th grade to due date of

application. May be photocopies that bear an original signature of the proper school authority. 5. SAT or ACT test scores must be included but may be photocopies. It is preferable that exhibits such as

awards and media items be photocopies. Include only one (1) set of scores of either Sat or ACT scores. 6. Applications must be properly bound on left side with hinges or staples in a standard binder or cover.

Elaborate bindings are discouraged. Clear plastic or bulky covers are undesirable. 7. Counting the application as 8-pages, the completed brochure must not exceed 25-pages (one side only) 8. The application must be arranged in the order described below:

a. Application of Required Facts. Carefully plan a response to each item before the final draft. Use 1 for freshmen year of school and 2, 3 and 4 for subsequent years to identify appropriate scholastic, extra curricular and civic activities. Secure all required dates.

b. MUST INCLUDE: The applicant shall prepare a statement of one (1) page or less using a

number 10 Arial or Times New Roman Font. The statement will in the applicant’s opinion define Americanism and why it is important today. It will also contain the applicant’s current and future commitment and demonstration of Americanism. This letter must be signed.

c. Official signed transcript of high school grades.

d. College entrance test scores required (SAT or ACT) – one (1) set only.

e. Current dated, signed one-page letters of recommendation from at least one person, but not

totaling more than three, in authority, from high school(s) and/or college attended by the applicant. Letter may cover the applicant’s ability, work habits, leadership, personality and integrity. An emphasis on the applicant’s commitment to Americanism is encouraged.

f. Two letters of endorsement from responsible community (non-school) persons. These persons

should not be related to the applicant. They should be capable of reporting the applicant’s participation in the community in terms of work service, leadership, notable skills and outstanding recognition. An emphasis on the applicant’s commitment to Americanism is encouraged. Each letter should be typed, dated, signed and no more than one sided of an 8 ½” X 11” page.

g. Copies of exhibits of achievement in scholarship, leadership, Americanism, athletics,

dramatics, community service or other activities may be attached – but avoid being repetitious.

Best Wishes & Good Luck!