DIANE CHRISTODOULOU MEMORIAL SCHOLARSHIP

APPLICATION
(to be completed by student)

I. STATEMENT OF INTENT

____________________________________________________________________________________________________________ submits the name of
NAME OF HIGH SCHOOL

___________________________________________________________________ as an applicant for the DIANE CHRISTODOULOU
STUDENT'S NAME

MEMORIAL SCHOLARSHIP. The applicant will graduate this spring and plans to continue his/her
higher education in a post-secondary program.
II. STUDENT'S INFORMATION
________________________________________ _____________________ _______ _____________

HOME ADDRESS

CITY MO ZIP CODE
________________________________ ____________________ _______ _____________
HOME PHONE SSN    
III. SCHOOL INFORMATION
__________________________________ __________________ _______ ______________
SCHOOL ADDRESS CITY MO ZIPCODE
______________________________ ____________________ ________ _______________
SCHOOL PHONE COUNSELOR OR TEACHER'S E-MAIL  

IV. COLLEGE, UNIVERSITY, OR OTHER INSTITUTION STUDENT PLANS TO ATTEND

_______________________________________ ________________________ ________  
FIRST CHOICE THIRD CHOICE    
______________________________________ ________________________ ________  
SECOND CHOICE FOURTH CHOICE    
V. AUTHORIZING SIGNATURES
________________________________________ _____________________ ________ ____________
STUDENT'S SIGNATURE   DATE  
________________________________________________________________
COUNSELOR, TEACHER, OR ADMINISTRATOR'S NAME      
________________________________________________________________ _______________________
PRINCIPAL OR COUNSELOR'S SIGNATURE   DATE  
Application deadline - March 30, 2008
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

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