100 Grange Place
Cortland, New York 13045
Telephone (607) 756-7553 

The information contained herein will be treated in a strictly confidential and professional manner.

	

Established in 1973, this endowment fund was established by the New York State Grange.   An award is made to a student in any class in the College of Agriculture and Life Sciences at Cornell. Selection is based on character, scholastic record, and need for financial assistance.  The award amount is determined by the Cornell Endowment Fund

Applicant Information

Name  	                                                               	
	(First, Middle, Last)

Home Address  	
	(Number and street)

(City)							(State)	(Zip)

Cell Phone                                                                 
Home Phone                                                                
Email                                                                       
Date of birth		

Father’s name in full  	                                                                                                                          
Father’s occupation  	                                                                                                                          
Father’s annual income  	                                                                                                                          
Mother’s name in full  	                                                                                                                          
Mother’s occupation                                                                                                                                        
Mother’s annual income                                                                                                                                  

List names and ages of brothers and sisters and if they attend college and where.

List any additional dependents:

Do you reside with your parents?       If not, with whom?  	

Cornell University 

What major and minor do you plan to pursue?  	
If in college, what college are you attending?  		
What major are you pursuing?                                                                                     

The statements included above accurately reflect my application.

SIGNATURE  	

GRANGE INFORMATION

		I am not a member of the Grange.  Grange membership is not a requirement for receipt of this scholarship.

			I am a member in good standing of		 Grange No.           in	                               county. 

Scholarship Application Check List

Please review this check list and ensure all required items are included with your application form.

The deadline for the following items to arrive in the office of the New York State Grange either via Mail or electronically at nysgrange@nysgrange.org  by June 1st at 11:59 PM.

Please Include:
		This Scholarship Application Form

		Maximum one-page essay answering the following question (250-word limit per question)
•	What is your intended college major and why have you chosen this career path?

		Please attach a small photograph of yourself for publicity (Photograph is optional and will not affect selection process)