THE SULLIVAN COUNTY SCHOLARSHIP FUND
created by Alton Taylor
Completed application and all supporting documentation must be returned to:
Your Guidance Office by Friday, April 26
th
, 2019 or
Citizens & Northern Bank by Monday, April 29
th
, 2019
Please type or print in ink
PERSONAL DATA
NAME: _____________________________________________________________
ADDRESS: ___________________________________________________________
CITY: _____________________ STATE: _______________ ZIP: _______________
TELEPHONE: Home: ____________________ Cell: _________________________
DATE OF BIRTH: __________ EMAIL ADDRESS: ____________________________
FATHER’S NAME: _______________________Cell: _________________________
OCCUPATION: _______________________ EMPLOYER: _____________________
MOTHER’S NAME:_______________________ Cell: _________________________
OCCUPATION: _______________________ EMPLOYER: _____________________
PARENT(S) EMAIL:_____________________________________________________
NUMBER OF BROTHERS AND SISTERS: __________________________________
Are any of them attending college? __________ If yes how many?________________
If so, indicate where they are attending:_____________________________________
_____________________________________________________________________
Do you live with: Both Parents: ____ Mother: ____ Father: ____ Other:_____________
If someone other than your parents supports you, please indicate:
NAME: ________________________ RELATIONSHIP: ________________________
ADDRESS: ___________________________________________________________
CITY: ____________________ STATE: _______________ ZIP: ________________
OCCUPATION: ______________________ EMPLOYER: ______________________
Name: _____________________
Please attach additional sheets if needed for activities, keeping the same format
EMPLOYMENT (During high school years only)
Employer Type of Work No. of Hours Dates of employment
Per Week From: To:
Example: John Doe Restaurant Wait staff 10 07/01/17 to 02/15/17
_______________________ ______________ _________ ____________________
_______________________ ______________ _________ ____________________
_______________________ ______________ _________ ____________________
Do you plan to work part time during the college year? __________________________
Do you plan to work during the summer? ____________________________________
COMMUNITY & VOLUNTEER ACTIVITIES (During high school years only)
Organization Name Type of Activity No. of Hours Dates of Involvement
Per Week From: To:
Example: Big Brothers/Big Sisters Mentoring 3 10/01/17 to present
________________________ _____________ _________ ____________________
________________________ _____________ _________ ____________________
________________________ _____________ _________ ____________________
Indicate what types of activities you plan to participate in while attending college, if any?
______________________________________________________________________
______________________________________________________________________
SCHOOL ACTIVITIES (During high school years only)
Organization/Sport Type of Activity No. Hours Weeks Number of
Per Week Per Year: Years::
Example: Student Government leadership 4 36 2
_________________________ _______________ _________ _________ _______
_________________________ _______________ _________ _________ _______
_________________________ _______________ _________ _________ _______
Will you be involved in any school activities while attending college? ______________
If yes, what types of activities? ____________________________________________
______________________________________________________________________
Name: _____________________
COLLEGE AND CAREER GOALS
What major will you pursue? ______________________________________________
What degree do you expect to receive? _____________________________________
What are your plans after receiving your degree? ______________________________
_____________________________________________________________________
_____________________________________________________________________
COLLEGE COSTS FOR YOUR FRESHMAN YEAR (Do not include personal
expenses)
Name of college you plan to attend: ________________________________________
Tuition and Fees: ______________________________________________________
Room and Board: ______________________________________________________
Books and Supplies: ____________________________________________________
First alternate college you plan to attend: ____________________________________
Tuition and Fees: _______________________________________________________
Room and Board: _______________________________________________________
Books and Supplies: ____________________________________________________
Please attach a copy of tuition/cost page from the above referenced schools, your
stude
nt financial aid package and any acceptance letters you have received.
Total Cost: __________________________________________________________________
Total Cost: ____________________________________________________________
Name: _____________________
FINANCIAL INFORMATION
To be considered for this Scholarship it is required that you supply the following
information:
Adjusted Gross Income (AGI) (parents filing separately should list each parentsAGI):
Parents: __________________________________________
Student: ___________________________________________
Expected Family Contribution (EFC) from your Free Application for Federal Student Aid
(FAFSA). You are required to attach the first page of your FAFSA Electronic
Student Aid Report (SAR) showing your EFC ("Viewing your processed information"
upon logging into your FAFSA account will take you to the SAR.)
EFC: _______________________
List any unusual expenses or circumstances your parent or guardian has: ___________
______________________________________________________________________
EDUCATIONAL INFORMATION
GPA ______________
Please attach a copy of your official high school transcript.
REFERENCES
Please attach to this application a total of two letters of reference, from people who are
not related to you.
The first letter must be from a non-school related individual. We suggest employers,
business people, and organization leaders.
The second letter must be from a teacher, coach, activity leader, or a member of the
administrative staff from the school you currently attend or have formerly attended.
School Personnel should use the “School District Recommendation form, following.
Name: _____________________
The Sullivan County Scholarship Fund
Created by Alton Taylor
  
School District Recommendation
Applicants: Recommendation to be completed by a teacher, coach, advisor or administrator
School District Personnel: please rate the personal qualities of this student as; outstanding,
above average, average, or below average. A written recommendation is also required. Please
use the space below and attach a separate sheet if necessary.
School District Personnel’s written recommendation:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
School District: ________________________________________________________________
Position: ____________________________________________________________________
School District Personnel’s printed name: ___________________________________________
School District Personnel’s signature: _____________________________________________
(Signature) (Date)
Quality
Outstanding
Above
Average
Average
Below
Average
Cooperativeness
Respect
Initiative/work ethic
Leadership
Personal Conduct
Trustworthiness
Maturity
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signature
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Name: _____________________
ONLY COMPLETED APPLICATIONS ACCOMPANIED BY ALL REQUIRED
SUPPORTING DOCUMENTATION RECEIVED BY THE DEADLINE WILL BE
CONSIDERED FOR THIS SCHOLARSHIP.
Citizens & Northern Bank
Trust and Financial Management Group
1827 Elmira St
Sayre PA 18840
1-888-760-8192
Completed Applications will include:
____ Signed and dated Application
____ Any Applicable Acceptance Letters
____ FAFSA with Estimated Family Contribution
____ Official Transcript
____ TWO Letters of Reference
One from member of the community
One from school district (“School District Recommendation” form)
Date
Applicant’s Signature
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signature
click to edit