Here is the application for the Ruby Rutnik Scholarship. Please see the eligibility requirements and instructions on how to apply by clicking here for previous story.
To apply using this form, print this form by hitting file/print, complete it and send it to the address below or drop off at Connections, Cruz Bay or Coral Bay.
Ruby Rutnik Scholarship Fund, Inc.
PO Box 348, St. John VI 00831
340/776-6809 T/F
APPLICATION — PART I
[to be completed by applicant]
1. Applicant:
_______________________________________________________________________
2. a) Home address: ______________________________________Telephone:
_________________
b) Mailing address:
________________________________________________________________
3. a) Place of Birth: _______________________________ b) Date of
Birth: ___________________
4. a) Citizenship: _________________________________ b) Social
Security No. ______________
5. Years resided on St. John:
___________________________________________________________
6. Present School:
___________________________________________________________________
7. Years in attendance:
_______________________________________________________________
8. Extra-curricular activities in school, incl. length of
participation: _________________________
_________________________________________________________________________________
_________________________________________________________________________________
9. Hobbies and interests:
______________________________________________________________
_________________________________________________________________________________
10. Volunteer work:
_________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
11. Summer or part-time jobs (employer and dates of
employment):_________________________
_________________________________________________________________________________
_________________________________________________________________________________
12. Colleges to which you have applied in order of preference:
(Please note if you have or have not been accepted and the
annual tuition amount)
13. What type of major are you seeking?
_______________________________________________
14. What other scholarship assistance have you applied for or have you
already been offered?
_________________________________________________________________________________
_________________________________________________________________________________
15. Name and address of teacher, supervisor/employer or others who are
submitting letters of recommendation on your behalf (please submit 2):
a. Current teacher:
_______________________________________________________________
b. Former or current employer/supervisor:
___________________________________________
c. Person (not family) who knows you:
______________________________________________
16. S.A.T. Score Verbal:_______________ Math:________________
Signature of Applicant: ________________________________________ Date:
________________
I/we have verified the S.A.T. score provided above, and, further, I/we
recommend for this scholarship the applicant whose signature appears
above.
Principal ______________________________ Date: ________________
Guidance Counselor ________________________ Date: ________________
NOTE: The submission of false information or the withholding of
information requested on this application will disqualify the applicant
from consideration for or the receipt of benefits from the Ruby Rutnik
Scholarship Fund, Inc.
Ruby Rutnik Scholarship Fund, Inc.
PO Box 348, St. John VI 00831 340/776-6809 T/F
APPLICATION — PART II
[to be completed by parent(s)/guardian(s)]
Please note: It is in the applicant's best interest that all questions
be answered fully to give a true and accurate picture of your financial
situation. The submission of false information or the withholding of
information requested on this application will disqualify the applicant
from consideration for, or receipt of, benefits from the Ruby Rutnik
Scholarship Fund, Inc.
1. Name of Applicant:
______________________________________________________________
2. If applicant receives or is eligible for other educational benefits,
complete the following:
AMOUNT OF SOCIAL SECURITY BENEFITS
to be received per year $ ________________________________________
AMOUNT OF OTHER EDUCATION BENEFITS
to be received per year $ ________________________________________
Please name the source of available educational benefits described as
"Other":
_________________________________________________________________________________
_________________________________________________________________________________
How long is the applicant eligible for the above benefits? _______
years or _______ months.
3. Father or Male Guardian
Name:
__________________________________________________________________________
Marital status: Married______ Separated______
Divorced______ Widowed______
Home address:
___________________________________________________________________
Date of birth: __________________________ Social Security Number:
____________________
Occupation: _____________________________
Employer:______________________________
Address:
________________________________________________________________________
Number of years: _________ Adj. gross income from 1999 tax return
$___________________
Citizen of: _____________________________Years resided on St.
John:____________________
4. Mother or Female Guardian
Name:
__________________________________________________________________________
Marital status: Married______ Separated______
Divorced______ Widowed______
Home address:
___________________________________________________________________
Date of birth: __________________________ Social Security Number:
____________________
Occupation: _____________________________
Employer:______________________________
Address:
________________________________________________________________________
Number of years: _________ Adj. gross income from 1999 tax return
$___________________
Citizen of: _____________________________Years resided on St.
John:____________________
5. Do both parents contribute to the applicant's support?
_________________________________________________________________________________
6. Brothers and Sisters of Applicant
School or Tuition Paid Aid Received
Name of Child Age College by Parent by Parent
_____________________ ______ _____________________ _____________
_____________
_____________________ ______ _____________________ _____________
_____________
_____________________ ______ _____________________ _____________
_____________
_____________________ ______ _____________________ _____________
_____________
_____________________ ______ _____________________ _____________
_____________
_____________________ ______ _____________________ _____________
_____________
7. Parent/Guardian Personal Assets and Indebtedness
a. Home, if owned: Purchase Real Property
Price Tax Appraisal Mortgage Balance
Year Purchased 19____ $________________ $______________
$_______________
Mortgage Holder's Name and
Address:____________________________________________
_____________________________________________________________________________
b. Other real estate: Purchase Real Property
Price Tax Appraisal Mortgage Balance
Year Purchased 19____ $________________ $______________
$_______________
Mortgage Holder's Name and
Address:_____________________
_______________________
_____________________________________________________________________________
c. Investments (stocks, bonds, other)
Please itemize. Purchase Price Market Value
Name_______________________________ $___________ $__________
Name_______________________________ $___________ $__________
d. Automobiles:
Cost Loan Balance
Make__________________Model_______Year____ $_____________
$____________
Make__________________Model_______Year____ $_____________
$____________
Name and Address of Bank or Finance Company
_____________________________________
____________________________________
_____________________________________
____________________________________
7. Parent/Guardian Personal Assets and Indebtedness (cont'd.)
e. Cash
Checking $______________________ Bank_________________ Acct
#_________________
Savings $______________________ Bank_________________ Acct
#_________________
Other $______________________
f. Other Assets. Please describe and establish value.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
g. Other Debts or Education Loans. Please itemize.
To whom owed _______________________________________ Balance
$_______________
To whom owed _______________________________________ Balance
$_______________
To whom owed _______________________________________ Balance
$_______________
8. Are there any other commitments or indebtedness that should be
considered in evaluating this applications? If so, please give details.
_________________________________________________________________________________
_________________________________________________________________________________
9. Are there any other funds that might be applied to the applicant's
education, such as legacies, gifts, trust funds, educational insurance,
child support, aid from relatives, friends or organizations? If so,
please give details.
Name of Source____________________________ Amount Available Annually
$____________
Name of Source____________________________ Amount Available Annually
$____________
I hereby attest that the information provided on this application is
accurate and complete.
Signature of mother or female guardian ______________________________
Date_____________
Signature of father or male guardian
______________________________ Date____________
COUNSELOR'S EVALUATION FORM
Name of
Applicant:___________________________________________________________________
A. CHARACTER AND PERSONALITY:
1. INITIATIVE (resourcefulness and originality in planning):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
2. LEADERSHIP (ability to influence others):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
3. CHARACTER (developed moral sense, adherence to ideals):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
4. INDUSTRY (application to work and acceptance of responsibility):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
5. COOPERATIVENESS (ability to work with others):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
6. DEPENDABILITY (meets obligations):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
7. APPEARANCE (grooming, appropriateness of dress):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
8. POISE (social effectiveness in meeting situaitons,
self-confidence):
Excellent___________ Good_____________ Poor______________
Additional comment
___________________________________________________________
B. SCHOLARSHIP:
Number of students in graduating class:______________
Applicant's rank in graduating class: ______________
Scholastic average: _____________
C. REMARKS:
I recommend the applicant for scholarship financial assistance.
Yes ____________ No ______________
Qualified recommendation
(explain):_______________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
__________________________________________ ____________________________
Counselor's Signature Date
