MEDINA COUNTY AUDITOR’S OFFICE SCHOLARSHIP
AUDITOR MICHAEL E. KOVACK

Applications due by April 9, 2010

Mail to:
Medina County Auditor’s Office
144 N. Broadway, Room 306
Medina, OH 44256

NAME: _____________________________________________________________________

HOME SCHOOL: _______________________ GPA: _____ CLASS STANDING: ________

HOME ADDRESS: ___________________________________________________________

TELEPHONE NUMBER: _______________________

PARENTS’ OR GUARDIAN’S NAMES: _________________________________________

FAMILY SIZE: _____________________ FAMILY GROSS INCOME: _______________
Name of college, business school, technical school, junior college or other school you plan to attend: ______________________________________________________________________________
Have you been accepted for admittance at this time? ______________________________________________________________________________
Intended major: ______________________________________________________________________________
Briefly explain how or why you selected the above major.
____________________________________________________________________________________________________________________________________________________________
Please list all of the high school/community-related activities in which you have been engaged and the years of participation. Also, include any employment history
you may have. Attach additional sheet of paper, if necessary.
____________________________________________________________________________________________________________________________________________________________
List special recognition, prizes, contest or honors you have received in the school or community.
____________________________________________________________________________________________________________________________________________________________

Write a brief essay explaining why this scholarship is important to you. Attach an additional sheet of paper, if necessary.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

**** All of the information in this application will be kept in the strictest confidence****

A copy of my transcript is attached to this application for the screening committee to study.

Counselor’s Signature: _________________________________ Date: ______________