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Get Shelter Insurance S-32-S

What college do you plan to attend Must be no later than the September following high school graduation. Please list all other scholarships awards or financial aids for which you have applied or have been granted indicate which for the coming school years. Name of Financial Aid S-32-S Value Has it been granted to you Page 1 What will be your major college study and what are your educational plans The applicant herewith consents that the Scholarship Selection Committee be fully informed as to the applicant s scholastic standing character and other factors having a bearing on this application. The applicant attests that he/she is not a natural born or legally adopted child of any Shelter Insurance employee or salaried/contracted agent. Gary Riepl Agent Name Agent Number 24-B684-32 Name of High School Central High School APPLICATION FOR SHELTER INSURANCE FOUNDATION SCHOLARSHIP This scholarship is offered only to graduating seniors at high schools where a Shelter Insurance Agent is actively participating in the Shelter Insurance Foundation Scholarship Program for the current school year. This scholarship application will be accepted only if the applicant is attending a high school that is currently sponsored by a local Shelter Insurance Agent. Section I. Information to be supplied by applicant Please print or type Full Name First Male Female Middle Last Birth Date Full Name of Parent s or Guardian Mailing Address of Parent s or Guardian street or route town county state zip E-Mail Address print clearly or type Phone Number include area code In the space below briefly summarize your school and community activities. List organizations of which you are a member and offices held. Additional information may be attached if necessary. What college do you plan to attend Must be no later than the September following high school graduation* Please list all other scholarships awards or financial aids for which you have applied or have been granted indicate which for the coming school years. Name of Financial Aid S-32-S Value Has it been granted to you Page 1 What will be your major college study and what are your educational plans The applicant herewith consents that the Scholarship Selection Committee be fully informed as to the applicant s scholastic standing character and other factors having a bearing on this application* The applicant attests that he/she is not a natural born or legally adopted child of any Shelter Insurance employee or salaried/contracted agent. Signature of Applicant After you have completed your part of this application present this to your Principal or Counselor for certification and delivery to the Scholarship Selection Committee designated by the Shelter Insurance Agent. This is to certify that the above applicant ranks in a class of 338 seniors. May 25 2014 Date of high school graduation will be taken the following college entrance examinations under a statewide testing program Name of Test Dated this Score day of. Signature of Principal or Counselor Central High School 2602 Edmond Street St* Joseph MO 64501 Address of High School Name of Shelter Insurance Agent 24-B684-32 Agent Page 2. .

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