APPLICATION FORM

BILLY D. YOUNG TELEPHONE PIONEER MEMORIAL SCHOLARSHIP APPLICATION

NAME: LAST____________________, FIRST_______________________,

MIDDLE______________________ (CIRCLE NAME YOU GO BY)

ADDRESS:

STREET:____________________________ OR P.O. BOX _____________

CITY____________________STATE__________ZIP CODE ____________

DATE OF BIRTH: ________/________/_________

TELEPHONE NUMBER:______________________ E-Mail:_______________________________

SEX: MALE________ FEMALE_________

NAME OF PARENT OR GUARDIAN:_______________________________

PARENT/GUARDIAN EMPLOYED BY*:_____________________________

*Parent or Guardian must be employed by a member or associate member of the TELSE

or a member of the Mid-South Chapter Independent Telephone Pioneer Association.

NAME AND ADDRESS OF HIGH SCHOOL ATTENDED OR COLLEGE ATTENDING

SCHOOL NAME:_______________________________________________

STREET ADDRESS:____________________________________________

CITY:___________________STATE_________ZIP CODE______________

YEAR OF HIGH SCHOOL GRADUATION:___________________________

YEAR OF PREVIOUS SCHOLARSHIP APPLICATION:_________________

ACADEMIC INFORMATION

OFFICIAL CUMULATIVE GRADE POINT AVERAGE AT THE END OF YOUR HIGH

SCHOOL JUNIOR YEAR BASED ON THE 4.0 SCALE: _______________________

CLASS RANK IN HIGH SCHOOL AT END OF YOUR JUNIOR YEAR: ___________

SIZE OF YOUR ENTIRE HIGH SCHOOL CLASS: ___________________________

IF SCHOOL DOES NOT RANK STUDENTS, ASK GUIDANCE COUNSELOR FOR AN ALTERNATIVE STANDARD, SUCH AS IN THE TOP 1% OF CLASS:____________

TYPE OF SCHOOL (PUBLIC, PRIVATE OR PAROCHIAL):____________________

COLLEGE ATTENDING IF APPLICABLE:__________________________________

GRADE POINT AVERAGE (COLLEGE IF APPLICABLE): _____________________

SCHOOL ACTIVITIES

LIST ALL SCHOOL RELATED ACTIVITIES (CLUBS, SPORTS, NEWSPAPER STAFF, AWARDS RECEIVED, ETC.)

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COMMUNITY ACTIVITIES

LIST ANY COMMUNITY OR CHURCH RELATED ACTIVITIES (VOLUNTEER WORK, CHURCH YOUTH ORGANIZATIONS, BOY SCOUTS/GIRL SCOUTS, ETC.)

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EMPLOYMENT ACTIVITIES

LIST ALL PAID EMPLOYMENT INCLUDING ANY SUMMER JOBS

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EXTRACURRICULAR ACTIVITIES

LIST ANY HOBBIES AND INTERESTS THAT YOU HAVE

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