DAVIS-ROBERTS SCHOLARSHIP FUND, INC.

APPLICATION FOR EDUCATION ASISTANCE

Application for school year: ____________  (Application Deadline: June 15th)

I.  Personal Information:

1. Applicant’s Name: ________________________________________________________________________  Age: _______

                                                 (Last)                                                 (First)                                         (M.I.)

2.  Address (Street, City, State, Zip Code): ____________________________________________________________________

     _________________________________________________________________    Home Phone: _______________________

3.  Place of Birth: ___________________________________________________      Birth Date:__________________________
(City)                                                (State)                                                        (Day-Month-Year)

4.  Father’s (Guardian’s) Name: __________________________________________   Occupation: _______________________

     Address: _______________________________________________________    Income Source: ________________________

5.  Mother’s Name: _____________________________________________________    Occupation: ______________________

Address: _______________________________________________________    Income Source: _______________________

6.  Number of Brothers and Sisters: _____________________________    Their Ages: ________________________________

7.  Number of family members in college at the same time as the applicant: _________________________________________

8.  Your Youth Group Body: __________________________________________    City: _______________________________

II. Education:  Schools Attended:                                                                                     Years                          Degree
Completed:                Received:
1.  ________________________________________________________________     1  2  3  4                    __________________
(Name of School and Location)

     2.  ________________________________________________________________      1  2  3  4                   ___________________
(Name of School and Location)

1. Grade Point Average: ________________ (A = 4)

1. Attending What College:  _______________________________________________________________________________

Location: ______________________________________________    Planned Major: _______________________________

     5.   List Offices/Honors/Awards held or received while in school: __________________________________________________

            ______________________________________________________________________________________________________

           ______________________________________________________________________________________________________

           ______________________________________________________________________________________________________

III. Out of School, Civic, and Community Activities: ______________________________________________________________

____________________________________________________________________________________________________________

IV. Positions held in gainful employment for the last Two Years:
Employer:                                                  Type of Work:                            How Long:                                           Wages:

      _________________________________________________________________________________________________________

      _________________________________________________________________________________________________________

V.  Applied For or Received Scholarships or Financial Aid: _________________________________________________________

       ________________________________________________________________________________________________________

       ________________________________________________________________________________________________________

       ________________________________________________________________________________________________________

       ________________________________________________________________________________________________________

VI. List Two (2) People (Non Relatives) whom we may contact (by permission) regarding your character:

       1.  Name: ____________________________________________________________   Occupation: _______________________

            Address: __________________________________________________________   Telephone No: _____________________

       2.  Name: ____________________________________________________________    Occupation: ______________________

            Address: __________________________________________________________    Telephone No: ____________________

VII.  Essential Details Required For Application Submission:

         1.    Include a letter of endorsement from a responsible person, not related to you, who can give an opinion as to your  character,
industry, disposition, and general worthiness.

1. Include a letter of endorsement from the adult leader of your Masonic Youth Group relating to your need and overall worthiness.

1. Include an Official Transcript of your previous year’s school grades.

1. Include a recent Head and Shoulders photograph of yourself.  (NOTE:  If awarded a scholarship, the photograph will be published in one of our Masonic publications.  Acceptance of the scholarship provides your permission for us to publish the photograph.)

1. Include an explanation of why you wish to continue your education.  The explanation should not exceed 200 words and should be in your own handwriting.

1. You may include articles, photographs, newspaper clippings, etc. that you deem important.

1. NOTE:  Incomplete application forms or applications submitted without all of the required essential details will not be considered.

_________________________           _____________________________________________________________________________
(Date Signed)                                                                (Signature of Applicant)

Mail completed application with all required essential details to:  DAVIS-ROBERTS SCHOLARSHIP FUND, INC.,
P.O. BOX 20645, CHEYENNE, WY 82003  so that it is received No Later Than June 15th of the year.

COMMITTEE REPORT:

APPROVED: __________________           DISAPPROVED: ___________________          AMOUNT:  $________

2-21-2010 updated