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GFA Scholarship Application 2010 (Submit these pages plus response to essay
question, extra credit (optional) and transcripts, etc., by March 31, 2010.
See main page Scholarships for details
To submit electronically, cut and paste into email or Word document, complete
form and return to
Contact@griswoldfamily.org.
The Griswold Family Association of America, Inc.
STUDENT APPLICATION
GRISWOLD FAMILY ASSOCIATION SCHOLARSHIP
Name and address of GFA member of relationship to applicant:
_______________________________________________________________________________
Griswold Line (please circle one): Edward Michael Matthew Francis
APPLICANT INFORMATION: (Please print legibly)
Name _______________________________SSN or student number______________
Last First M.I.
Home Mailing Address __________________________________________________________
Home Phone ( )____________ Date of Birth _____E-mail address______________
Father or Guardian Name ________________________________________________________
Mother or Guardian Name _______________________________________________________
1. U. S. Citizen? Yes _______ No __________
2. High School(s) Attended?
______________________________________________________
______________________________________________________
3. High School Graduation Date ____________________
4. Institution of higher learning to which applicant's scholarship award is
requested (if known; we recognize that some have college applications pending on
admission results):
Institution Location Major
______________________________________________________________________
5. Will you commute from home? ___ Live on Campus? ___ Off-campus
apartment?________
6. Parent's or Guardian's occupation:
Occupation Employer
Father ___________________ __________________________________________
Mother __________________ __________________________________________
7. Other family members in same household:
Relationship Age Status (Employed-student-etc.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
8. Other scholarships, grants, loans, etc. you are seeking or have received:
Source Amount Sought Amount Received
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PLEASE COMPLETE IN DETAIL THE FOLLOWING QUESTIONS. ATTACH ADDITIONAL SHEETS OF
PAPER FOR COMPLETE ANSWERS AND IDENTIFY WITH APPROPRIATE LETTERS:
A. Describe your work experience, indicating period of time in each job, rates
of pay, and duties/responsibilities.
B. List your memberships and participation in school and community organizations
and activities.
C. Prepare a statement of your aspirations, and give other information you feel
will help the award selection committee.
D. Indicate unusual family or personal circumstances, if any, which you feel
warrant the attention of the award selection committee.
I hereby give permission to my high school to release a copy of my transcripts
of grades, class rank, college board scores. I further certify that the
information contained in this application is complete and accurate, to the best
of my knowledge.
Applicant's signature ______________________________
TO THE APPLICANT'S HIGH SCHOOL COUNSELOR (if applicable): Please attach comments
about any unusual factors which you feel warrant special attention, and attach
applicant's class rank, college board scores, and official transcript.
Counselor's Signature _____________________________
Financial Data
The Griswold Family Association of America, Inc.
Applicant Name ____________________________________________________
Part II - Financial data to be completed by parent or guardian. Please take the
information from your completed 2008 IRS income tax return (1040, 1040A, or
1040EZ) or preferably from your 2009 return, if it is completed.
A. Adjusted gross income $ ___________
B. Total US tax paid ___________
C. Income earned from work by: Father ___________
Mother ___________
D. Non-taxable income: Social Security, Child support, Welfare,
Tax-exempt interest, Veteran's benefits, etc. ___________
E. Medical/Dental expenses not paid by insurance ___________
F. Total number of exemptions ___________
G. Total savings and investments at December 31, 2009 (cash, savings
and checking accounts, stocks, bonds, mutual funds, CD's, etc.) ___________
H. Applicant's parents' marital status is _____ married_______ single____
separated_____ divorced_______ widowed_______
I. Total of family members who will be attending post-secondary school at least
half-time during 2009-2010 school year (include applicant) ___________
Part III - Certification and Signatures
Certification: All of the information on this form is true and complete to the
best of my (our) knowl edge. If asked by an authorized official, I (we) agree to
provide proof of the information I (we) have given on this form. I (we) realize
that this proof may include a certified copy of my (our) U. S. Income Tax
Return. I (we) also realize that if I (we) do not provide such proof if asked,
the applicant may not receive scholarship aid.
Signatures:
Applicant _________________
Parent/Guardian ___________________
Date ___________________
To submit electronically, cut and paste into email or Word document, complete
form and return to
Contact@griswoldfamily.org.
Scholarships-main page
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