Directions for submitting application:

1. The following credentials must be filed with this application.

A. Official copy of High school or College transcript

B. Photograph (senior year picture)

2. Deadline for submitting this application is April 1. The application and the above credentials should be returned to:   Chairman of the Scholarship Committee, Blue Ridge Lions Club, P. O. Box 146, Blue Ridge Summit, PA 17214.

Students Name: Last First Middle                                                                                                      

Address: Street Telephone                                                                                                                                              

City State Zip Code                                                                                                                                                             

Date and Place of Birth:                                                                                                                                                                          

High School: Name Cumulative GPA                                                                              

Date of Graduation                                       

Number in Class                                         

 Rank in Class                                                                                                                          

College you plan to attend:                                                                                                                                                          

Name of College Date of Acceptance                                                                                                                                       

Second Choice Date of Acceptance                                                                                                                                                   

College Major Estimated Total Cost For a Year                                                                               

(Room - Board - Tuition)

List other sources of financial aid for which you applied:                                                                                                                       

Extra-Curricular/Out of School Activities

Participation in extra-currilular activities. Indicate Offices held in class or school organizations:

year, e.g., Band 3,4. (State only major activities.)

Out of school activities, offices held, awards and                                                                                                                           

Honors and awards: work experience:                                                                                                                                           

Family Data

Address                                                                                                                                                                                                                                                  

Employer                                                                                                                                                                                                                                      

Address                                                                                                                                                                                                                                                       

Employer                                                                                                                                                                                                                                       

Please explain in this space any special family circumstances that the Committee should be aware of.                                                                                      

(Please indicate why you are applying for this scholarship. Use additional pages if necessary.)