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Kiwanis Louisiana-Mississippi-West Tennessee District Foundation

2008-2009 LaMissTenn Circle K District Scholarship Program Sponsored by the Louisiana-Mississippi-West Tennessee Kiwanis District Foundation, Inc.

PURPOSE: The LaMissTenn Circle K District Scholarship Program, sponsored by the La.-Miss.-W.Tenn. Kiwanis District Foundation, is designed to provide recognition and financial assistance to Circle K members who have excelled in their collegiate careers. It is designed for Circle K'ers who have achieved academic excellence, demonstrated leadership abilities and provided service to others. Financial need will not be a factor in this award.

QUALIFICATIONS: 1. The applicant must be a member of a Circle K Club within the La.-Miss.-W.Tenn. District, and be in good standing with the home club, the district and Circle K International. 2. The applicant must have full-time student status during the current administrative year and be in good standing with said enrolled college or university. 3. The applicant must have a grade point average equivalent of a 3.0 or better on a 4.0 scale.

APPLICATION REQUIREMENTS: (all information must be typewritten or computer-generated)  This 3-page application form must be fully completed and properly signed.  Two (2) passport photos that meet U.S. Passport regulations for possible publicity purposes. You can obtain these at a FedEx-Kinko’s, Walgreen’s, Wal-Mart, or another similar retail store that offers passport photos.  One (1) letter of recommendation from a member of the Kiwanis Club that sponsors the applicant’s Circle K Club.  One (1) letter of recommendation from a member of the applicant’s Circle K Club.  A two-page (typed and double-spaced) essay answering the question: "How has your involvement in Circle K made you more aware of the needs of other people?"

 An official transcript.  A letter of verification concerning student status from the Dean of Students/School Registrar  The application, including all supporting documents requested, must be mailed to:

LaMissTenn CIRCLE K DISTRICT SCHOLARSHIP PROGRAM P.O. Box 14026 * Baton Rouge, LA 70898-4026 NOTE: It is important to remember that this Official Application Form MUST be used for these scholarships in order to be considered. Also, if all of the items requested above are not included, the applicant may not be considered for these awards. Application materials become the property of the La.-Miss.-W.Tenn. District and will not be returned.

Deadline for submitting application package: Postmarked by January 30, 2009


2008-2009 LaMissTenn Circle K District Scholarship Program (Please type all data)

PERSONAL DATA NAME ____________________________________________________ last first middle

S.S. # ______-_____-________

MEMBER, CIRCLE K CLUB OF: _________________________________________________________ CURRENT ACADEMIC STATUS:  Freshman SophomoreJunior

Senior going directly to graduate school

Graduate Student

CAMPUS ADDRESS: ____________________________________________________________________ street apt. number ____________________________________________________________________ city state zip code HOME ADDRESS:

____________________________________________________________________ street apt. number ____________________________________________________________________ city state zip code

PHONE NUMBERS: (_____)________________ (_____)________________ (_____)________________ campus home mobile

UNDERGRADUATE ACADEMIC DATA Major(s): _______________________________________________________________________________ Minor(s): _______________________________________________________________________________ In the School of__________________________________________ (e.g., business, liberal arts, fine arts, etc.) Cumulative Grade Point Average: ___________________________________________________________ Undergraduate institution(s): University or College:

Dates:

Major:

Degree:

____________________________________ ____________ __________________ _______________ ____________________________________ ____________ __________________ _______________ ____________________________________ ____________ __________________ _______________

OFFICIAL APPLICATION FORM – Page 1 of 3


GRADUATE ACADEMIC DATA Cumulative Grade Point Average: Graduate Study: University or College:

Date Applied:

Date Accepted: Field of Study:

_____________________________________

______________

_____________

_________________

_____________________________________

______________

_____________

_________________

_____________________________________

______________

_____________

_________________

For what vocation will your course of study prepare you? Career Goal/Expectations:

ACADEMIC PLANS Institution attending for 2008-2009 academic year: Mailing Address: City: _______________________________________________ State: __________ Zip Code: If no acceptance at this time, please check here:

CIRCLE K DATA Date and Circle K Club joined: Offices held and other Circle K involvement (include years served):

Check the percentage of the following that you attended or participated in during this past year: 1-24% 25-49% 50-74% 75-100% Club Meetings      Club Service Projects 

Club Fundraisers



Club Social Events



List District events you have attended (e.g., Fall Training Conferences, District Board Meetings, Rallies). Include the years: District Conventions attended (list by years): International Conventions attended (list by years):

OFFICIAL APPLICATION FORM – Page 2 of 3


(List the years of involvement with each item)

OTHER INFORMATION

Campus Activities/Offices:

Honoraries/Awards:

Community Activities: Name of Hometown Newspaper: Address: street

city

state

zip code

Name and address of the President of the college/university where you earned/are earning your undergraduate degree: name address

title city

state

zip code

Name and address of the President of the college/university you wish to attend/are attending for your graduate degree: name address

title city

state

zip code

STATEMENT OF INTENTION I hereby state my intention to enroll in school and pursue my educational objectives in the Fall of the 2008-09 academic year. Signature of Applicant: ______________________________________________ Date: ________________

CERTIFICATION I hereby certify that the application and supporting materials are correct to the best of my knowledge. Signature of Applicant: ______________________________________________ Date: ________________ Signature of Circle K Club President: ___________________________________ Date: ________________ Signature of Faculty or Kiwanis Advisor: ________________________________ Date: ________________

Mail completed application by January 30, 2009, to: LaMissTenn CIRCLE K DISTRICT SCHOLARSHIP PROGRAM P.O. Box 14026, Baton Rouge, LA 70898-4026

OFFICIAL APPLICATION FORM – Page 3 of 3


OFFRICIAL APPLICATION FORM