1. Name ______________________________ Date of Birth ____________________

2. Mailing address ______________________________________________________

________________________________________________________

3. Permanent address ____________________________________________________

________________________________________________________

4. Telephone( )__________________ 5. Social Security # ___________________

(If you have been out of High School for more than 5 years skip to number 11)

6. ACT or SAT Scores: Verbal______ Math ______ Eng .______ Math ______

                                        Soc. Studies ______ Sci. ______ Comp.______

7. GPA ______(through last grading period) rank# _____out of class size of _____

8. Name of high school and mailing address: ________________________________

_______________________________________________________________________

9. High school counselor: _________________________________________________

                        Telephone: __________________________

10. List any academic honors, any awards, and any extra curricular activities in

which you participated. Include any leadership roles and special recognitions.

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

11. Attach a copy of your high school transcript (and college if attended) to the

      application.

12. Include three sealed letters of recommendation.

13. Attach an essay of 100-200 words which includes (a) a discussion of your career

    objectives; (b) an explanation of why you need scholarship assistance; (c) the

    amount of financial assistance needed from this Foundation; (d) the name of the

    college in which you intend to enroll; and (e) the semester you intend to enroll.

14. List all of the scholarships and financial aid for which you have applied.

________________________________________________________________________

________________________________________________________________________

Have you received any financial aid to go to college and if so how much? _________

Have you applied for a PELL Grant? ________ How much was awarded? _______

ALL APPLICANTS MUST APPLY FOR F.A.F.S.A. (Pell Grant). We must have a

copy of your letter of denial or your letter stating the amount of your Pell funding.

        above 60.000_____.

16. Name, address, and telephone number of parents or guardians, OR spouse, and

________________________________________________________________________

________________________________________________________________________

17. Number brothers/sisters ____________; total number in household ___________

18. Beginning with the most recent give the name, address, phone number, and

        date(s) of employment of your latest three (if more than three) employers:

A. __________________________________________________________________

__________________________________________________________________

B. __________________________________________________________________

__________________________________________________________________

C. __________________________________________________________________

__________________________________________________________________

19. Are there any special or unusual problems or circumstances of which the

    selection committee should be aware?

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

20. I certify that the above information is true and accurate:

_________________________________ ______________________________

                (Signature)                                     (Date)

21. Applications will not be reviewed until all information requested is received.

    address:

TRI STATE EDUCATIONAL FOUNDATION

POST OFFICE BOX 58

IUKA, MS 38852