Medina County Auditor's Office:
Scholarship Application

Please print and complete the application below.  Make sure to review the scholarship rules before applying.  All applications are due by April 15, 2012.

Please mail applications to:
Medina County Auditor's Office
144 N. Broadway St., Room 306
Medina, OH 44256

Name: _____________________________________________________________________

Home school: _________________________ GPA: ______  Class standing: ____________

Home address: ______________________________________________________________

Telephone number: ___________________________________________________________

Parents' or guardians' 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.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

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

Counselor’s Signature: ________________________________________  Date: ________________



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