APPLICANTS NAME:__________________________________________________________

1. The entries on this application form must be complete, accurate, and legible. They must be typewritten or printed in black ink. Use separate sheet of paper to complete each part if more space is required.

2. Review the form for completeness and all answers for correctness. Sign the application form.

3. Mail the completed application to: Association of Minemen
                                                        Attn: Scholarship Chairperson
                                                        P.O. Box 69
                                                        Eutawville, SC 29048-0069

Applicant Name:____________________________________________________________

Permanent Address:__________________________________________________________

Temporary Address:__________________________________________________________

Home Phone Number:____________________ School Phone Number:_____________________

Date of Birth:____________________________ Sex:_______ Marital Status:________________

Number of Dependents, if any:_____ Are you a member of any ROTC(s) program?:___________

Current Academic Status (Check One): High School Graduate or GED:______________

                                                             Current College Undergraduate:_____________

                                                              College Graduate Student:_________________

List total annual amount of tuition, room, board, and other fees:_________________________

List any educational resources expected to receive: Vets Benefits:___________________

                                                                             Social Security:__________________

                                                                             Grants:________________________

                                                                           Scholarship:_____________________