100 Grange Place, Cortland, New York 13045
Telephone (607) 756-7553 FAX (607) 756-7757

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

STUDENT APPLICATION FOR UNDERGRADUATE SCHOLARSHIP GRANT
The deadline for the application packet to arrive in the office of the New York State Grange either via Mail or electronically at nysgrange@nysgrange.org  by April 15th at 11:59 PM.

Please check  (x) all applicable:
 		DeNise Agriculture Scholarship - Membership/Participation must be in your resume in at least ONE of the following: 
•	FFA  
•	Skills USA
•	4-H
•	FCCLA
•	Grange
		Susan Freestone Education Fund (Grange membership required see description for details)

		Clifford D. Herman Scholarship (Grange or FFA membership required see description for details)

		June Gill Nursing Fund (Grange membership required see description for details)

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?  	

COLLEGE
What colleges have you applied or are currently attending:
College	Estimated Tuition	Applied	Accepted 	Enrolled	

					

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

		I was a member of		Junior Grange No.   	 in	                                                                      county for	 years.

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

			I hold the following Degrees:
Junior	4th	5th	6th	7th  	

Signature of Subordinate Grange Secretary (or alternate if secretary is a relative) affirming membership in good-standing.

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 April 15th at 11:59 PM.

Please Include:

		School Evaluation Form – Print this form from the New York State Grange web site which can be found here.

		This Scholarship Application Form

		One letter of recommendation

		Copy of Resume including the following areas: 
•	Career Goal
•	Educational History
•	Work Experience
•	School Activities (sports, clubs, FFA, FCCLA, FBLA etc.)
•	Community Involvement (Grange, church, 4-H etc.)
•	Special Awards & Recognition

		Maximum one-page essay answering the following questions (250-word limit per question)
•	What is your intended college major and why have you chosen this career path?
•	Grange is a service centered organization. Why is it important for people to be involved with their community and ho;w have you been involved with your local community?

		Most recent transcript if currently attending college.
	
		Please attach a small photograph of yourself for publicity (Photograph is optional and will not affect selection process)

June Gill Award Only
		Written statement on “Why nursing is a career for me” June Gill Award Only