Name:

First:

Middle:

Last:

 Address:

City:

State:

Zip:

 Date of Birth:

Citizenship:

SS#:

Phone:

 DRG Sponsor:

Sponsor’s e-mail address:

Business Phone:

 High School

Date of Graduation:

High School GPA:

 Attended:

 High School Counselor

 Name:

Phone:

 ACT Composite Score:

Date Taken:

SA T Composite:

Date Taken:

 Attach official high school transcript and official ACT and SAT test score results.

 What college do you plan to attend?

 In what field do you plan to major?

 Please attach three letters of reference, two academic and one personal.

 Describe any extra curricular activities in which you participated.

  Awards received:

 Please attach a one (1) page maximum statement describing your career goals.

 I certify that all entries on this application are complete and accurate to the best of my knowledge.

 I understand that falsifying any part of this application may result in the disqualification for the DRG scholarship.

 Signature:

Date: