Application

LOTT Enterprises of Maryland Scholarship
Foundation Incorporated
2015 College Scholarship Application
Eligibility:
U.S. Citizen Residing in St. Mary's County
Minority Student
2015 graduating high school senior
Instructions:
please complete Parts 1 through 3 of this application and submit completed application
and all requested zupplemental information by
Application Checklist
April30' 2015.
:
Part 1 Personal and Financial Data (Page 2)
Financial information is to be completed by Parent or Guardian. The Parent or
Guardian who completes this section must provide their signature.
PartZ School, Community Involvement, andEssay @age 3)
On a separate sheet of paper, compose and submit a short essay on the
significance of a college d"gre" for a minority student and how yow degree
assist you in pursuing your career goals.
will
part 3 College Acceptance, Profile, Transcript, and Lettcr of Recommendation
Grg* A) Submit one (1) letter of recommendation from an individual in your
ichool or community who can best describe your character, accomplishments and
need for a scholarship. The letter of recommendation must include the name,
phone number(s) and title of the person writing it Youmay include the letter of
i"ro**.ndation with your application or it may be mailed directly to the address
below.
Disclaimer: By signing below, I certify that my answets are true and complete to the best of my
knowledge. I have readthe instructions carefully. I am providing ALL informationrequested and I
have completed this application in accordance with the checklist above. I understand that
representatives of LOTT Enterprises of Maryland Scholarship Foundation Incorporated
notiff me if infonnation is missing and my application will be disqualified.
Applicant's Signature
Seholarship Deadline: Submit completed application by April30' 2015.
Mail to:
LOTT Enterprises of Maryland Scholarship
Foundation IncorPorated
ATTN: Sylvia ThomPson Brown
P.O. Box 1591
Lexington Park, Maryland 20653
will not
LOTT Enterprises of Maryland Seholarship Foundation Incorporated
201 5 College Scholarship Application
College Acceptancq Profile, Transcrip! and LJttrof Recommendation. part 3
Name of applicant
TO BE COMPLETED BYA SCIIOOL REPRESEMATIYE
Name of Applicant's Sclrool Counselor:
Prnase ENcLosE.dN oFFICIAL HIGE scgool TRANscRrpr FoR TrrrsAppLIcANT
Has the applicant submitted an application for admission to an accredited
IIas the applicant been accepted?
Yes_
institution?
yes
No
No
Ifyes, please list nam{s) of institution(s
Please rate the following based on your personal knowledge of the applicant:
Need for financial assistance
Interest in post secondary education
Aptitude for post secondary education
Probability of completing college
Unknown
Unknown
Unlnown
Unknown
Low
Moderate
H€h
Low
Moderate
High
Low
Moderate
Hish
Low
Moderce
High
Additional comments (optional)
Signdure of School Representative completing .lis section
Title of School Representative completing this section
Date signed
RETT'RN TEIS FORM AND AN OFFICIAL SCHOOL TRANSCRIPT
TO TTIE APPLICANT IN A SEALED
Er\wELOpE BEFORE TnE ApRIL 30, 2015 DEAIILINE.
APPLICAIYT: REMEMBER To SITBMIT oNE LETTER oF RECOMMENDATION.
The letter ofrecommenddion
it. vou mav ioroa" tir rgtter ofrecommendation
must include the name, phone number(s) and title ofthe person writing
with your application or it may be mailed directly to:
IOTT Enterprisas of Maryland Scholarship
Foundation Incorporated
ATTN: SyMa Thompson Brown
P.O. Box 1591
Lexington Parlg Maryland 20653
LOTT Enterprises of Maryland Scholarship Foundation Incorporated
College Scholarship Application
School, Community Involvement and Essay Part2
201 5
Name of applicant
Complete the following to the best of your ability. Please do not send original documents-
SAT
1
AP Tests (optional)
ttttltl
ttlrl'
Verbel Mtth Dste
ACT (if
applicable)
Verbal Math Date
Subject
II Subjects
Writins
Math
SAT
Subject
Score
Tests (optionaf)
ScorelDatc
Score/Date
Composite Score/Date
Score
Score/Date
High School Activities
Dates
Leadership Roles
Community Service/Employment
Dates
Leadership Roles
List all awards, scholarships, publications, or special recognitions you have received. For scholarshipsr list the amount and
frequency of award.
If necessary, please continue
on another sheet of paper.
On a separate sheet of paper, compose and submit a short essay on the significance of a college degree for a minority student
and how your degree will assist you in pursuing your career goals.
LOTT Enterprises of Maryland Scholarship Foundation Incorporated
Application
Personal and Financial Data Part 1
201 5 College Scholarship
Congratulations on your irnpending high school diploma and your pursuit of post secondary education. LOTT
Enterprises of Maryland Scholarship f,'oundation Incorporated is a minority investment goup which
encourages higher education for today's minority youth. LOTT Enterprises of Maryland Scholarship
Foundation Incorporated will award college scholarships to students enrolled in a public or private high
school located in St. Mary's County. Eligible students are minorityU.S. citizens who have applied and been
accepted to a post secondary institution for the Fall of 2015. They must also demonshate a financial need for a
scholarship and have established leadership responsibilities in their schools and community.
Pnnsoxer, Dara (Tvrn oR pRrNT
rN BLAcK oR BLUE nvx
oNr,v.)
Full Legal Name:
First
Male/Female
Middle
Phone Number
Mailing Address:
City
zip
State
Physical Address:
zip
City
High School:
State
City
** * * *2t f.2t * * ?k:t* rt * tr:t tr*:l:b:t * *frrr *fr * *t * * * *?t*** ls f.* Cr *:klcts:b
To gu coMPLETED BY PARENT OR GU.I.NNU.U
rsts
* rs*:tt Ltr*
Zip
fr
* fs:t rr *
Signature of ParenVGuardian completing this section
F TTmn/MILE
MoTHER/FEMALE GUARDIAN
GUARDIAN
Name
Relationship to
Applicant
Ages ofApplicant's
Siblings
Relationship to
Occupation
Ages of Applicant's Siblings
Tohlfncome
Adjusted Gross lncome
(1{X0 or 1M0A)
(104O 1040A, or
Tarable Incom e
(I(MIOEZ)
Applicant
Occupation
Other Income (See Note
Below)
Taxable Income
Occupation
Adjusted Grosg Income
(1040, 10404, or 1040E2)
Total Income
(1040 or1040A)
1040E2)
Occupation
(1040E2)
Other Incone (See Note Below)
Note: For *Other Income", total any other sources ofincome you may receive not already included as Total Income (e.g. Soeial Seeurity,
Military Allotment, etc.).
2