Eligibility
Students must meet these criteria to be eligible. Please select answer.
I confirm that I am in financial need for this scholarship
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Yes
No
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I attend High School in Pike County, Illinois
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Yes
No
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I will be attending a college or university
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Yes
No
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Personal Information
Name (First, Middle, Last)
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Social Security Number
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Telephone
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Email Address
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Home Address
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City, State, Zip
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High School Attended
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County
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Length of residence in this county (years)
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Name of Parent or Guardian
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Address
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City, State, Zip
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Date and Place of Birth
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Is anyone dependent on you for support?
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Yes
No
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If yes, name and relationship
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How many family members will be attending college full-time during the next four years?
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Please list their names, relationship and years they will be attending college:
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College Information
Name of college you are planning to attend
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Location of College
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Anticipated cost of the first year's tuition, room & board and books
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Financial Need Information
Check any of the applicable items below to indicate how you plan to pay your expenses not covered by the scholarship:
Money furnished by family
Earnings during the summer
Student Employment
Student Loans
Other means
Please list other means
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Are you aware of other monetary awards you are receiving?
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Yes
No
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If so, please list:
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As financial need is a requirement for this scholarship, you must attach a copy of pages one and two of your parents' and your Federal Income Tax Returns.
File is required
The consideration for this award is financial need. If there are special circumstances you feel the selection committee should be aware of, please describe below:
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High School Activities and Community Activities
Please list below activities in which you have participated during your high school career. (include high school activities and community activities)
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Special Honors and Awards
Please list below any special honors or awards received in high school or in the community while in high school.
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Essay
Please write below a short essay describing your career plans
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Transcript
Please upload High School transcript or have guidance office send transcript to trust@farmersstate.com (PDF files please)
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Acknowledgment
I certify that, to the best of my knowledge, all information given on this application is true and correct.
Date
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Signature (please type name)
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