Social Security Number  -- 

Candidate's 
Full Name:     

Home 
Address:      
                     
                     

School Name: 

School 
Address        
                      
                      

Telephone Number
Home:       School: 

Expected Degree and Major:  

College Entrance Scores 

ACT 

Current Major:

College academic awards or honors:

College etracurricular activities (including offices held):

Other outside activities:

Work experience (if any)
:

Signature:    Date: //

Along with this completed application you MUST include

• An official and complete transcript of all your college or university work

• Two letters of recommendation from faculty members familiar with  your work.

After completing this form, highlight the form and print on 8 1/2" x 11" paper, or request a form from Gene Blake, Chairman and mail or fax this form with the additional required information as noted above.