Personal Data

Name:
Social Security No. (no dashes or spaces):
Address:
City:
State:
Zip:
Telephone (sample: 308-999-9999):
Birthdate (mm-dd-yy):

Both parents' names & address(es) - names only if address is the same as above
Father:
Mother:

Educational Background/Program

1) From what high school did you graduate?
2) Date of high school graduation: Month: January February March April May June July August September October November December Year:
3) School you plan to attend during 2009-2010:
4) Address of school:
    Is this a 4-year college?
    Is this a 2-year vocational / technical college?
5) College/Department enrolled in (i.e. teaching, business, arts & sciences):
   
6) What is your major?   minor?
8) How many credit hours do you plan to carry? Less Than Half Time Half Time Full Time

Work Experience

List your past and present work experience:

References: 
(Please include only two letters unless more are required to meet criteria of scholarships applied for)

List individuals from whom you have requested letters of recommendation:

Please check the appropriate box(es) below to the scholarship(s) you are applying for:
(See complete list of all available scholarships and scholarship requirements by clicking here.)

(Scholarships with an (*) above are based on financial need. Please click here for Financial Need Information Form. 
If financial need information is not provided, you will not be considered for these scholarships. Remember to select the "back" button on your browser to return to this application once you have completed and printed the Financial Need form.)

Describe Your Campus Activities (volunteering, athletics, etc.): 

Church/Religious and Community Activities: 

Essay:
If an essay is required for the scholarship you are applying for, please refer 
to the scholarship requirement form to see which of the below questions you will need to 
cover in your essay. Type your essay response in the box below.
There is a 300 word limit.

Essay Questions: (* Required essay questions. **As required for specific scholarships.)
1: Why are you continuing your education?*
2: What are your professional/educational goals and how will you achieve them?*
3: How have you shown leadership in contributing to your community?**
4: How have you demonstrated strong character such as responsibility, maturity, judgment and integrity?**
5: What are your financial needs and how will a scholarship benefit your educational goals?**
6: How has 4-H and/or FFA prepared you for the future?**
7: How have you demonstrated perseverance, high character and high effort to overcome a handicap?**

Responses to above questions should be kept to appx. 100 words.  


All Applicants:
Enter your email address so we may contact you with any questions.
Email:

*Optional* We request that you provide us with one photo of yourself. This photo is only used for publicity purposes if you are awarded a grant. Click here to access our photo uploading page.

Email Disclosure: All information submitted in this application is complete and accurate to the best of my knowledge. I understand that by signing this disclosure, I am giving my permission for the Merrick Foundation to use the information at its discretion for publicity purposes.

ELECTRONIC SIGNATURE: (Please type the last 5 digits of your social security no. to verify you have read and understand the above Email Disclosure:

For your records, it is recommend you print out the above application before hitting "Submit".