CITY OF LONDON/LONDON BRISGE ROTARY EDUCATIONAL

FOUNDATION

PO BOX 1590, Lake Havasu City, AZ 86405

APPLICATION FOR SCHOLARSHIP

Summer 2010

Applicant’s Name: ___________________________________ Date: __________________

Permanent Home Address: _________________________________ SS#: _____________

City: ______________________________ State: ___________ Zip: ___________________

Phone: (_____)_____________ Email: ________________________ Fax: _______________

Date of Birth: _________________________ Place of Birth: _________________________

Sex: Female( ) Male( ) Marital Status: Single( ) Married( ) Other( )

Current Mailing Address : _______________________________________________________

City: ______________________ State: _______ Zip: ______________

Phone: (_____)______________ Fax: _______________ Email: _______________________

As of June 1, 2010, what level of study will you have completed:

Freshman( ) Sophomore( ) Junior( ) Senior( ) Graduate School( )

Major: ___________________ Minor: _ ___________________ Degree: ________________

G.P.A. _______ Expected Date of Graduation: ___________ State of Residency: ________

School Attending/Plans for Next Year: ____________________________________________________

Name and address of graduating high school: ______________________________________

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High school Class Rank: ______ High school G.P.A. ______ Year of graduation: _______

Previous studies aboard: _______________________________________________________

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Your plans upon graduation: ___________________________________________________

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Distinctions, honors and awards: _________________________________________________

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Office and Positions: ___________________________________________________________

School and Community Activities: ________________________________________________

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Required Attachments: Personal Essay, Transcripts & Two Recommendation Letters.

MAIL HARD COPY TO ADDRESS ABOVE. NO EMAIL APPLICATIONS.