Student's Full Name ...................................................................................................Phone No..........................................................

Student's 'Address...............................................................................................................................................................................
     Street city City, State, Zip
Schools attended (9th - 12th).............................................................................................................................................................
    Name of School Date of Entrance Period Attended
..........................................................................................................................................................................................................
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Father's Name................................................................age .................Occupation.............................................................................
Mother's Name...............................................................age..................Occupation.............................................................................
School Honors and Awards (State Year and nature of award)..............................................................................................................
.............................................................................................................................................................................................................
............................................................................................................................................................................................................
Positions and offices of leadership in school:......................................................................................................................................
...........................................................................................................................................................................................................
Have you been granted scholarship aid? .......................If so, give details............................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
Do your intend to apply for aid from any other source? ...............If so, give details:..........................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
Any additional data to show financial need and general worthiness. Be specific:................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................
...........................................................................................................................................................................................................

    This application, with attached exhibits, has been reviewed, the statements verified.
Date    Lodge Name: ................................................No................. State.........................................
Signed.......................................................................................................................(Lodge Scholarship Chair, Exalted Ruler or Secy)

Is Handicap permanent?.................. (Explain if necessary)....................................................................
.................................................................................................................................................................
.................................................................................................................................................................
        applicant's signature.......................................................................................................

    Father's Income before taxes            $__________
    (annual)
    Mother's Income before taxes            $__________
    (annual)    Gross Annual Income total of above    $__________

Number of dependents EXCLUDING Mother and Father____________

Number of dependents attending college ____________

Medical and Dental expenses not paid by insurance        $__________

Emergency Expenses (flood damage, etc.)        $__________

Total Market Value of Home            $__________

Amount of unpaid Mortgage            $__________

Do you own a farm or business? YES NO

If so, what is the market value'?        $__________

What is the NET profit?            $__________

Value of bank accounts            $__________

Value of other investments , stocks, etc.)        $__________

Any unusual circumstances, please explain:
.................................................................................................................................................................
.................................................................................................................................................................

Does father or mother have a pension plan other than Social Security?_________yes__________ no

Date............ Signed by    ________________________________________ father
        _______________________________________ mother

General Instructions:
         1.    Applicant must use official Utah Elks Association Form. Typewritten applications and statements are preferred over handwritten submissions and must be signed in all instances.

        2.    Applicants may include letters of recommendations from two school related sources and two or three letters from sources outside school. The letters must be originals on one side of a single sheet of 8 1/2" x 11" paper signed by the author.

        3.    A supporting letter from a doctor stating the continuing nature of the handicap must be included with the application. A letter from the high school principal stating his knowledge of applicant should also be included.

        4.    Official High School Records, transcripts, etc. from the beginning of the ninth grade to date of application may be photocopies that bear an original signature of the proper high school authority.

        5.    The applicant shall prepare a statement of 300 words or less setting forth his or her goals and relating how past, present and future activities make the realization of

the goal probable. The statement must be signed.

        6.    The parent or guardian shall prepare a statement of 200 words or less summarizing the obligations and resources of the family. This statement needs to illustrate the families' need for assistance and the inability of the family to satisfy these needs. Other types of aid from whatever source need to be listed and explained.

        7.    Total length of the completed application, which is to be placed on folder bound on the left side, may not exceed 20 pages.

        8.    Exhibit of achievements or honors received may be included in the application.

        9.    Elaborate presentation of material is not necessary. The use of plastic sheets to cover pages is discouraged.

    Note: If additional space is needed for any item(s), a separate sheet may be used and placed immediately following the application form.