Brotherhood Achladokambiton       

                                                       Scholarship Form

Please, print this form complete and mail it to:

Brotherhood Achladokambiton

5424 North Milwaukee Ave.

Chicago, Illinois 60630

                                                APPLICATION FOR SCHOLARSHIP AWARD

                                                                            FROM

                                            FRATERNITY ACHLADOCABITON "ST. DEMETRIOS"

                                                                    CHICAGO, ILLINOIS

INSTRUCTIONS

    A. All questions must be answered completely.

    B. Print in blue ink.

    C. Your application form must be signed by the high school principal.

    D. A transcript of your high school.

PERSONAL DATA

      1. Date of this application ______________________

      2. Full Name _______________________________________________

      3. Present Address __________________________________________

                                   __________________________________________

      4. Present Phone Number _____________________________________

      5. Name of Parents or Legal Guardian ___________________________

      6. Address of Parents or Legal Guardian ___________________________

      7. Place of Your Parents Birth ___________________________________

     8. Date of Your Birth ___________________________________________

    9. Place of Your Birth ___________________________________________

EDUCATION

    1. Name of High School _________________________________________

    2. Address of High School _______________________________________

    3. Full Name of Principal _________________________________________

    4. High School Phone Number ____________________________________

    5. When will you be graduated from High School? ____________________

    6. How many students in your class? ______________________________

    7. Is your grade average in the upper 25% of your class?  yes____ no____

    8. Indicate yearly high school grade average, to date on chart below.

9. In which high school courses are you most interested?

    NAME OF COURSE____________________ NAME OF COURSE___________________

10. In what activities have you engaged? _________________________________

11. Have you attended any other high schools, trade or vocational schools? Please list:

      ______________________________________________________________

12. When do you plan to enter college?    month _________ year _________

13. What University / College will you attend? _______________________

REFERENCES

List the names addresses of three adults that have known you at least three years and who could

give information concerning your personal characteristics.

1. Name _________________________________ Address_________________________

2. Name _________________________________ Address_________________________

3. Name _________________________________ Address_________________________

   APPLICANT __________________________________

   HIGH SCHOOL PRINCIPAL ____________________________

DO NOT WRITE BELOW THIS LINE

____________________________________________________________________________________