APPLICATION FOR ROCKY IVEY MEMORIAL SCHOLARSHIP Full Name:______________________________________________________________ Home Address:___________________________________________________________ Telephone No.:___________________________________________________________ Date of Birth:____________________________________________________________ Social Security No.:_______________________________________________________ Father’s Name:___________________________________________________________ Father’s Address:_________________________________________________________ Father’s Occupation:_______________________________________________________ Mother’s Name:__________________________________________________________ Mother’s Address:_________________________________________________________ Mother’s Occupation:______________________________________________________ Gross Family Income:______________________________________________________ Number of Children in Family:__________

Ages:_________________________

Number of Children in College:______________________________________________ College or University to be Attended:_________________________________________ (Copy of Letter of Acceptance Must be Attached) High School GPA:__________________________ Participation in activities, offices and honors: School:___________________________________________________________ ________________________________________________________________________ Community or Church:_______________________________________________

Application is due by April 1st of the application year.