SCHOLARSHIP APPLICATION
(Sponsored by Horace Mann Insurance)

Please follow these instructions carefully to be considered for the scholarship:

1. Either type your responses on this form or print legibly with black ink.
2. Be sure you and your parents sign and date this application and your selection sheet.
3. Attach a resume of your activities, honors, awards, and community involvement.
4. Request one letter of recommendation from a teacher, coach, or organizational sponsor.
Submit the application and resume to the NSIAAA no later than March 6.

High School ___________________________________________________________________

ACT Composite Score __________ Your Class Rank ___________ Class Size ____________

School Administrators Signature _________________________________________________

Last Name ___________________First Name__________________Middle Initial ___

Home Address __________________________________________________________

Phone ______________________________ Email _____________________________

Father’s Full Name ______________________________________________________

Father’s Occupation _____________________________________________________

Mother’s Full Name _____________________________________________________

Mother’s Occupation ____________________________________________________

List names and ages of Siblings ____________________________________________

List the Colleges, universities, community colleges, or vocational/technical schools you are considering in order of preference:

First Choice _____________________________________________________________

Second Choice ___________________________________________________________

Third Choice ____________________________________________________________

What is your intended major ______________________________________________

What two high school activities have been your major focuses and what contributions have you made to these activities?

What activities outside of school have you been involved with the most (i.e., community organizations, volunteer work, etc.) and what contributions have you made to these activities?

Work Experience:  List the place you have worked, dates of employment, and an approximate number of hours per week that you worked.

Employer __________________________  Employer ___________________________
Position ____________________________ Position ____________________________
Hours per Week ______                               Hours per Week ______
Dates of Employment ________________  Dates of Employment ________________

List all scholarships you have been awarded as of the date of this application.

Scholarship:  ____________________________________________Amount ________

Scholarship:  ____________________________________________Amount ________

Scholarship:  ____________________________________________ Amount ________

Why do you feel that you are deserving of a scholarship?

What are your goals for the future?  Include how these goals were developed, what you have done to prepare for these goals, and what you need to accomplish in the future to attain these goals.  Please write this section in your own handwriting.  It must be brief and legible.  (You may use an attached paper for this section)

Please read and sign this statement of assurance:  We certify that all information on this form is accurate.  We authorize the release of this form, the resume, and the letter of recommendation to be used by the selection committee.

Student’s Signature _____________________________________ Date ____________

Parent’s Signature ______________________________________ Date ____________