Application – Prince Hall Memorial Education and Scholarship Fund

Name *

First

Last

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

County *

Home Phone #: *

Cell Phone #: *

Email: *

Is any member of your family associated with any Masonic group *

Yes
No

If "yes", please list the organization:

College, University, or school of interest: *

Expected field(s) of study: *

High School Attended: *

High School Address (Street/City/State/Zip):

School/Community/Church Activities: *

After School/Summer jobs held: *

Honors/Awards Received

Upload picture: *

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List any scholarship awards you have received for next year and their value: *

TOTAL ANNUAL FAMILY INCOME: *

NUMBER IN FAMILY: *

Name and Address of Parent or Legal Guardian: *

First

Last

Address:

Address Line 1

Address Line 2

City

State

Zip Code

County:

Signature of Parent or Legal Guardian (type name here): *

Authorization of Parent or Legal Guardian for release and use of information by the PHMESF. This includes the use of student transcripts, progress reports, results of achievement or aptitude tests, or copies of personal evaluation reports. Verification of income is required if selected for a scholarship. By your signature you certify that the financial information provided is correct.

Signature of Student (type name here): *

Criteria considered for award selection: Student GPA; SAT or ACT test score; family income; number in family; school, community, and church activities; employment; teacher assessment; and essay.

Write a clear concise essay (500 words or less) on "What an education means to me". Attach completed essay: *

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Attach transcript: *

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Teacher Assessment(s) or Reference Letter(s) - Maximum of 3 *

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Teacher assessments, letters of reference

Results of achievement test (SAT or ACT):

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Lodge: *

Please select a lodge in your area of residence in order to have your application processed.