Scholarship Form
Permanent Address  
Email Address  
Telephone Number  
Name of parent(s) or guardian 
Name of high school  
Year of HS graduation  
Rank in class (i.e. 10/270) 
College, University or Technical School 
Equity location you or your parents market livestock 
Please indicate number of head or number of acres in the following 12 categories:
Dairy cows  
Dairy heifers & calves (if not applicable, leave blank) 
Beef Cattle (if not applicable, leave blank) 
Hogs (if not applicable, leave blank) 
Sheep (if not applicable, leave blank) 
Other (please specify)  
Crops (total acres)  
Other (specify)  
Leadership Positions held in all organizations (church, school, 4-H, FFA, etc.)  
Awards & Honors Received (Fairs, Shows, etc.)  
Describe your farm and future opportunities within your chosen field  
A summary of significant events in your life, describing educational goals and future career plans  
 Have you received or do you intend to apply for other scholarships?
Choose Yes or No    Yes
If yes, which scholarship(s) have you received or are you applying for?  
Are you receiving any other financial aid? 
Choose Yes or No    Yes
If yes, what?  
To verify cooperative member status, please include the patron name and number you or your parents market under (eight digits in upper right-hand corner of check stub which includes first two as association number). 
Farm Name  
 I hereby certify that the information contained within this application is true and to the best of my knowledge.
Check Box if you agree  
Date of application  
Campus Phone  
Campus Address  
How to fill out the Text Box  
Please type the text in the box.


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