Kentucky Transportation Employees’ Association

Scholarship Application

1.                  Applicant’s Name: __________________________________________________

(First)                          (Middle)                      (Last)

            Address:  Street  __________________________________________________________

                            City    ___________________________  Zip Code ______________________

                            County  __________________________  Phone  ________________________

            Date of Birth:  ________________ Social Security Number  _______________________

2.                  Family Information:

   Which parent is a member of the Association?  Father(    ) Mother(    ) Both(    )

Father:                                                                         Mother:

Name: _____________________________               Name: ________________________

Address: ___________________________               Address: ______________________

               ___________________________                              ______________________

Occupation:  ________________________               Occupation:  ___________________

Number of exemptions claimed on 2009 tax return_______ Ages _____________________

Number of dependents that will be a full time college student in 2010__________________

Adjusted gross income on 2009 Federal Income Tax Form 1040 ______________________

3.                  High School Information (High School Seniors Only)_____________________________

School Name ____________________________ Phone # _________________________

GPA ___________________________________ Point System Used ________________

You must attach your high school transcript and a letter of acceptance to the school you plan to attend in the fall.

4.                  College Information

Hours earned _______________ GPA ________________ Point System Used ________

Academic Counselor’s Name _______________________ Phone#__________________

            You must attach your college transcript.

5.                  Scholarships and/or grants (do not include loans) you will receive.

________________________________________________________________________

I certify that the information presented is correct and accurate.  I understand and agree that if awarded a scholarship by the Kentucky Transportation Employees’ Association, any unused scholarship funds will be returned to the Association by the College or University at the end of the academic year.  I further understand that in the event of my withdrawal, expulsion or upon being placed on academic probation by the institution, any unused scholarship funds will be returned to the Association.

I understand that the scholarship is for one year only, and I MUST REAPPLY EACH YEAR.  I agree that in the event I should receive a full scholarship or grant from another source, not listed on this application, I will so inform the Scholarship Committee.  Failure to notify the committee could result in the withdrawal of scholarship funding.

Submit completed Application to                               ____________________________________

__________________________                                SIGNATURE OF APPLICANT         DATE          

By:   April 16^th 2010     

                                                                                    ____________________________________

                                                                                    SIGNATURE OF PARENT (Assoc. Member)

                                                                                                 (If deceased, please type name)