Herbert J. and Anna W. Cornwell
Memorial Scholarship
GUIDELINES AND ELIGIBILITY CRITERIA
1. Applicants must be a graduate from a Stafford County high school.
2. Recipients must enroll full time in an institution within the boundaries of Kansas.
3. Incomplete applications will not be considered nor will they be returned.
4. The applicant must have earned a minimum 2.75 GPA for the most recent semester in which he/she was enrolled.
5. To be considered, all applications must be postmarked or received by the 2nd Monday in June for fall semester
consideration or by the 2nd Monday in November for spring semester consideration.
6. Grades or correspondence from the student to the committee must be postmarked by January 15.
INSTRUCTIONS FOR COMPLETING THE APPLICATION
1. Application must be typed on this form. Complete the form and press the PRINT button at the top of this Page.
2. Completed applications must be assembled in the following order:
a. Typed application
b. Official high school transcript
c. Official transcripts from all post-secondary institutions (if applicable)
d. Two character references letters from non-family members must be submitted with the application.
INSTRUCTIONS FOR REAPPLICATION
1. Complete and mail only the “FACT SHEET” of the application and attach an official transcript from the current post-
secondary institution. Must be postmarked by the 2nd Monday in June.
2. If circumstances have changed considerably and you believe this would affect your scholarship, please fill out the
complete application.
SEND COMPLETED APPLICATIONS AND REAPPLICATIONS TO:
Cornwell Scholarship Committee
430 E. Broadway
P.O. Box 370
Stafford, KS 67578
Print Form
Cornwell Memorial Scholarship Application
FACT SHEET
Name of Applicant S.S.#
Permanent Address
(Street Address)
(City, State, Zip)
Telephone:
Telephone:
(City, State, Zip)
(Street Address)
College Address
Educational Background
Year and high school from which you graduted:
Please Check One: I am a first time applicant for Cornwell Scholarship
I am reapplying for the Cornwell Scholarship
I would like the commitee to review my scholarshi p due to a change in circumstances.
Fill in the blanks to indicate your plans for further education
I plan to enroll at
(name and location of school)
in
(month & year)
. I plan to obtain the followingto study in the field of
. At enrollment I will be classified as adegree
(Fr, So, Jr, Sr or Graduate)
CERTIFICATION STATEMENT
Please read and sign the following statement after completing the application.
"I certify that, to the best of my knowledge and belief, all information contained in this Scholarship application is accurate, true
and complete."
______________________________________
(Signature of applicant)
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STATEMENT OF FINANCIAL NEED
Are you claimed as a dependent on your parent's income tax return? YES NO
(If yes, you must furnish information for both yourself and your parents. If no, complete only "student" column)
Student Parent/guardian
Adjusted Gross Income (From income tax return)
Untaxed income & benefits
Social Security Benefits
Aid to Families with
Dependent children
AFCD or ADC
Child support received
Scholarships Awarded
Grants Awarded
** The selection committee reserves the right to request supporting documents.
In the space provided below, type a paragraph or more aimed at convincing the Scholarship Selection Committee that you need
financial assistance in order to continue you education. Include any extenuating circumstances that should be taken into
account when considering the financial status of the family (This could include outstanding loans, unusual medical bills, etc.)
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PAST ACADEMIC RECORD
1. On a 4.0 scale what is your current overall G.P.A.? or
High School College
2. If available, give the folloing information:
ACT Scores
English Mathematics Reading Sci. Reasoning WritingComposite
SAT Scores
AnalyticalQuantitativeVerbal
GRE Scores
3. In the space provided below, type a paragraph or more aimed at convincing the Scholarship Selection Committee that you
have demonstrated academic success in your past schooling and that you will be academically successful in your future schooling.
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EssayMultiple ChoiceWritingMathematicsCritical Reading
FUTURE PLANS
In the space below, type a paragraph or more summarizing your plans for the future. You might include details such as your
career plans, what you have done so far, and what still needs to be done to prepare for that career, how effective you will be in
contributing in that career etc.
Remember, your purpose is to inform.
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CITIZENSHIP AND COMMUNITY INVOLVEMENT
You previously related your aademic honors and achievements. In the space below, type a paragraph or more summarizing your
citizenship and contributions to you school and community through extra curricular activities, honors, leadership roles, and work
experience. You might want to include any other unusual or miscellaneous information about your background and/or your
plans that you believe the Scholarship Selection Committee should know about.
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