PURDUE ALUMNI CLUB OF CENTRAL IOWA SCHOLARSHIP
2012 Application Form
(Please type application)
APPLICANT:
PARENT(S) OR GUARDIAN:
Name:
*Address:
City:
County:
Telephone (cell):
Email address:
Name:
Address:
City:
Telephone:
Email address:
State:
Zip::
State:
Zip:
Picture Attached: Yes______ No________
*Please provide your school address if known
Counties includes in the Purdue Alumni Club of Central Iowa are: Adair, Boone, Clarke, Dallas, Greene, Guthrie, Jasper,
Lucas, Madison, Marion, Marshall, Monroe, Polk, Poweshiek, Story, Union, Warren. All student from Iowa are able to apply
but preference is given to those in the above counties.
High School Academic Information
Name of High School:
Graduation Date:
High School Rank :
ACT or SAT Score:
High School GPA:
Out of:
College Academic Information
Year:
Major:
Expected Graduation Date:
GPA:
Minor:
ESSAY
Please answer all four essay questions.
Provide a brief description of your high school, campus and community extracurricular activity involvement.
Please be sure to include the name of the organization, any position held and date of involvement. (attach
separately, if desired).
How do you feel that Purdue University will prepare you for your success, both in your intended major and in
general?
How will you be financing your college education and how will a scholarship impact your plans?
Is there any other information that we should know about you? This is your opportunity to include information that
is not contained in other areas of this application. Please be specific
I acknowledge that the information provided in this above application is correct to the best of my
knowledge and confirm that I satisfy all of the criteria for the Purdue Club of Central Iowa scholarship(s)
for which I am applying. Furthermore, I authorize Purdue University to release personally identifiable
information from my education record to the Purdue Club of Central Iowa for the purposes of
scholarship selection, and scholarship donors and/or the media for publicity purposes regarding the
awarding of a scholarship. This could include items such as my class, major and GPA but not my PUID.
If I am selected for a scholarship, award, or prize, I authorize Purdue University to release my name,
major and hometown to the donor(s) and confirm that all criteria for selection were met. In addition, I
agree to send a letter of appreciation to the donor and participate in events associated with any
scholarship, award, or prize I may receive.
Name:_____________________________________
Signature:_______________________________________
Date: ______________________________________
TERMS AND CONDITIONS
1.
The PURDUE CLUB OF CENTRAL IOWA SCHOLARSHIP is an award to enrolled recipients in an amount ranging
from $500 to $1,500 annually depending on funds available.
2.
Scholarship priority is given to resident of the area covered by the PURDUE CLUB OF CENTRAL IOWA. This area
includes the Iowa counties of:
Adair
Boone
Clarke
Dallas
Greene
Guthrie
Jasper
Lucas
Madison
Marion
Marshall
Monroe Union
Polk
Poweshiek
Story
Warren
3.
All applicants must submit an application form to the PURDUE ALUMNI CLUB OF CENTRAL IOWA and
POSTMARKED by NOVEMBER 15, 2012. Student who wish to email there applications may do so but they must
be sent to the email below before midnight on NOVEMBER 15, 2012.
4.
Primary focus shall be on applicants who are enrolled freshmen and new transfer students. Any PURDUE
UNIVERSITY undergraduate meeting the award requirements may also apply and will be considered. Any student
interested in applying should contact John Diekelmann (information below) if they have any questions.
5.
Applicants may be required to have a personal interview with Scholarship Committee prior to start of fall term.
6.
PURDUE UNIVERSITY will directly administer the scholarship through the Division of Financial Aid who will select
the recipient based on the recommendation of the PURDUE ALUMNI CLUB OF CENTRAL IOWA.
7.
The scholarship award is contingent upon the applicant being formally accepted by PURDUE UNIVERSITY.
8.
The scholarship shall go only toward tuition and fees in two equal consecutive semester payments, beginning the 2nd
(spring) semester. In the event the selected applicant receives other scholarship(s) covering tuition and fees, funds
from this scholarship (up to the maximum award) will not exceed the remaining balance necessary to totally cover
tuition and fees.
9.
The scholarship recipient must maintain full time student status at PURDUE UNIVERSITY. Recipient may also
receive scholarship if they participate in a Co-op or intern project that continues to require Purdue University fees.
Student must maintain at least a GPA of 2.5 to receive the payment.
10.
Scholarship awards will be limited to a maximum of 4 years or 8 semesters for a student.
11.
The completed application form with attachments should be mailed or E-mailed to:
Jamie Mills
Scholarship Committee
Purdue Alumni Club of Central Iowa
8325 Colby Pkwy #526
Urbandale, IA 50322
Mills.Jamie.L@gmail.com
Phone: 765-366-9359