Full Name:

Years Performed in Junior Company:

Age:

Social Security Number:

Year in School:

Date of Birth:

Phone:

Address:

City:

State:

Zip Code:

Email Address :

Parent's Names:

Father's Occupation:

Mother's Occupation:

Names and Ages of Brothers and Sisters:

Special Training (music, drama, dancing, arts, etc.):

Outside Activities and Hobbies:

Work Experience (full or part time):

Other Accomplishments and Interesting Facts:

Scholarship Information (State college education, degree and/or special training you desire in using any scholarship grants you may receive from this program.):

Ambitions for the Future:

Use of Scholarship (In the space provided, please explain how you intend to use the Junior Company Foundation's Scholarship.):

We certify that the foregoing information is true and correct to the best of our knowledge.

Candidate's Signature:

Parent's Signature:

Date: