ࡱ> RTQW 5bjbj~~ 4Nee-,,qqqqqL,+++++++-0+q+qq+qq++)%+r%*++0,9*Z1l.Z1(%+Z1q%+x++.,Z1, 7: Tennessee Elks Benevolent Trust Application for Scholarship in Nursing This application must be filled out with the Scholarship Chairperson of the B. P.O. Elks Lodge Nearest to the applicants residence in order that it may be judged by the sponsoring Lodges Scholarship Committee and the Major Project Committee of the Tennessee Elks Association. Application must be turned in to the local lodge no later than February 15! (May be legibly written or typed) Applicants Full Name___________________________________________________________________________ Address_______________________________________________________________________________________ Street City State Zip Email Address_______________________________________________________________________________ Telephone Number__________________________________________________ Marital Status________________ Date of Birth_________________________________ Social Security Number______________________________ Name and Location of High School_________________________________________________________________ Date of Graduation_______________________________________________ Type of Diploma________________ Grad Point Average (4 years) ________________________ACT or SAT Score_____________________________ Offices Held in Class or School Organizations_______________________________________________________ If applicant has graduated from High School, list the name and location of all other schools attended or attending Out-of-School Activities: Awards, Offices, etc. ______________________________________________________ Volunteer Services (Church, Community, Hospitals, Nursing Homes, School) List the dates that the volunteer service was preformed and the average weekly hours for each separate activity. Service From Service To Location Hours Total Hours Sponsoring Lodge Endorsement This application and attachments have been reviewed, the contents verified, and found to be in conformity with the rules and regulations set forth by the Tennessee Elks Benevolent Trust. ___________________________________________ _____________________________________________ Chairperson, Lodge Scholarship Committee Date Exalted Ruler or Secretary Date __________________ Lodge No. _______ Applicants Signature Date Employment List dates of employment, and average weekly hours worked while attending school. Employed From To Employer Type of Job Average Hours If no employment or volunteer service, please explain why. _____________________________________________ Have you applied for or expect scholarship assistance from any other source? _________ If yes, please provide all details. _______________________________________________________________________________________ Name and location of the approved* school of nursing that you plan to attend. ______________________________ Upon completion of your training do you plan to remain in Tennessee? _________ If not, where? ______________ *Accredited school of nursing (college or hospital) in the state of Tennessee or any other school approved by the Executive Board of the Tennessee Elks Benevolent Trust. TO BE COMPLETED BY ALL APPLICANTS Budget for full academic year of ______ How many months ____________________ Tuition and Fees (full academic year, not monthly) $___________________________________ Books and Supplies $___________________________________ Room and Board $___________________________________ Travel $___________________________________ Total of Above $___________________________________ LESS ANTICIPATED INCOME: Parents Contribution $___________________________________ Students Contribution $___________________________________ Summer earnings $___________________________________ College Work/Study Employment $___________________________________ Other Scholarships, Grants, or Loans (details): $___________________________________ Total of Above $___________________________________ Amount needed to balance school budget for the year $___________________________________ In order to properly evaluate this application, the information on the next page is essential. Select the area which best fits the applicants circumstances. A dependent application is on who relies on his/her parents for the basic and major part of his/her support. An independent applicant is one who is on his/her own and derives the basic and major part of his/her support from himself/herself and/or a spouse. Incomplete information in this area will disqualify the applicant. I certify that the statements in this application are true. _____________________________ _________________________ ____________________________ Fathers signature Mothers signature Spouses signature TO BE COMPLETED BY UNMARRIED APPLICANTS DEPENDING ON PARENTS: Fathers name ________________________________________ Age: ______ Occupation: ____________________ Mothers name _______________________________________ Age: ______ Occupation: ____________________ Parents marital status Father: Married _________ Widowed _______ Divorced _________ Remarried______ Mother: Married _________ Widowed ________ Divorced ________ Remarried ______ Fathers annual income before taxes $___________________________________ Mothers annual income before taxes $___________________________________ Applicants annual income before taxes $___________________________________ All other taxable or non-taxable income not included above (Including pensions, Social Security/disability, interest, dividends, etc.) $___________________________________ Gross Income (total of above) $_____________________________ Number of Dependents (excluding father & mother) __________ Number of Dependents attending college at present time__________ Medical & Dental expenses not paid by insurance $___________________________________ Emergency expenses (flood damage, etc.) $___________________________________ Total market value of home $___________________________________ Amount of unpaid mortgage $___________________________________ If no home is owned amount of annual rent $___________________________________ Do you own a business or farm? ______ Market Value $__________________________________ What is the NET profit? $__________________________________ Value of bank accounts $__________________________________ Value of other investments (bonds, CDs, stocks, etc.) $__________________________________ Any unusual circumstances, please explain: __________________________________________________________ Does your father or mother have a pension plan other than Social Security? _______ Yes ________ No TO BE COMPLETED BY MARRIED OR INDEPENDENT APPLICANTS: Applicants marital status: Single ____________ Married ___________ Spouses name: _________________________________ Age: ______ Occupation: _________________________ Applicants annual income before taxes $___________________________________ Spouses annual income before taxes $___________________________________ All other taxable or non-taxable income not included above (Including pensions, Social Security/disability, interest, dividends, etc.) $___________________________________ Gross Income (total of above) $_____________________________ Number of Dependents (excluding applicant & spouse) __________ Is the applicants spouse attending school? __________ Medical & Dental expenses not paid by insurance $___________________________________ Emergency expenses (flood damage, etc.) $___________________________________ Total market value of home $___________________________________ Amount of unpaid mortgage $___________________________________ If no home is owned amount of annual rent $___________________________________ Do you own a business or farm? ______ Market Value $__________________________________ What is the NET profit? $__________________________________ Value of bank accounts $__________________________________ Value of other investments (bonds, CDs, stocks, etc.) $__________________________________ Any unusual circumstances, please explain: __________________________________________________________ GENERAL INSTURCTIONS The applicant must be a U. S. citizen, a high school senior or graduate of an accredited high school, GED is accepted. The applicant should reside in the jurisdiction (usually closest) of the Elks Lodge to which the application is submitted. The applicant and parents or guardian are required to complete all parts of the application form. Items not applicable must be marked N.A.. The following attachments must be included with each application: A letter from the applicant stating their reason for wishing to become a nurse (must be 400-500 words). A letter from the applicants parents regarding the need for financial support, if applicable. A transcript of the high school, GED, or nursing school scholastic record, including the school grade point average through the last reporting period prior to submission of an application; the results of ACT and/or SAT test; and the students ranking in their class. A letter from a high school guidance counselor, principle, or teacher evaluating the applicants ability to complete nurses training. In case of an applicant reapplying for a second scholarship, a letter from the Dean of Students or School Administrator will be required. A letter from the applicants employer or community leader concerning the applicants character, honesty, and dependability. Awards and pictorials. Total portfolio not to exceed 20 pages. Applicants must use the official TEBT application form (photocopies are accepted) that have been signed by the student, parent(s), or guardian(s), and lodge officials. High school, GED, College or Nursing School transcripts of student records may be photocopied. Photocopies of ACT, SAT, and other test results are also acceptable. All applications must be neatly bound on the left side in a standard binder (not a 3 ring notebook). Any identification of the applicant on the front cover is not necessary. All incomplete applications will not be considered for assistance. It is imperative that all information be set forth, especially as to your cost to attend your chose coarse, so that we may evaluate your needs. All scholarships are in the form of Certificates of Award issued by the Scholarship Secretary of the Tennessee Elks Benevolent Trust conditioned upon the enrollment of the student in an accredited school of nursing. Upon receipt of Verification of Enrollment completed by the proper school officials, a TEBT check in the amount of the scholarship award will be forwarded to the school to establish credit for the student, for the ensuing academic year. Payments may not be used to cover retroactive charges. JUDGING WILL BE FOR THE FOLLOWING: Scholastic Achievements: GPA, proficiency in subjects essential to nursing curriculum, honors, etc. Desire and Interest: Volunteer service, employment, motivation, good aptitude to the profession. Need: Financial need and resourcefulness. Brochure: Completeness, neatness, and following directions. 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