This application must be completed and returned by
to:
York County Conservation District
118 Pleasant Acres Road
York PA 17402
Phone: (717) 840-7190 Fax: (717) 755-0301
Name: _____________________________________________________________________________________
Social Security #: _______________________
Home Address: ______________________________________________________________________________
City/State: _____________________________________________ Zip Code: _______________________
Telephone: ( ) _______________________
College or University attending: _______________________________________________________________
Major course of study: ________________________________________________________________________
Present semester enrolled: ___________________________ Grade point average: ________________
(one year’s cost)
Total Cost of Tuition: $___________________ Cost of Room & Board: $___________________
Dollar amount to be provided by: (total of all of these should equal the total of tuition and room & board)
Employment $___________ Savings $___________ Loans $___________ Grants $___________
Scholarships $___________ Others $___________ Family $__________
Remaining Balance $___________
Mother ________________________________ Occupation _____________________________________
Father ________________________________ Occupation _____________________________________
Spouse ________________________________ Occupation ____________________________ _________
Return this form with all other required items in your application packet (transcripts, reference letters, statement of need, career goals, etc. See checklist for complete requirements)
________________________________________________________
Signature
_____________________
Date