SUMMIT ENDODONTIC SPECIALISTS, INC. 2015 Scholarship Application RONALD M. WOLF, D.D.S., M.S. Practice Limited to Endodontics www.Summit-Endo.com SCHOLARSHIP CRITERIA & REQUIREMENTS: - Two $500 scholarships (non-renewable) are available to students intending to enter the dental, medical or any science-related field. - Applicant must be a 2015 graduating high school senior. - Must have at least a cumulative 3.0 Grade Point Average (GPA) for junior and senior years in high school. - Selection will be based on merit, community service, and academic performance. - Scholarship application must include the following: - This completed application form with applicant’s signature. - Copy of official transcript of grades. - Letter of recommendation from your high school guidance counselor, teacher or health care professional addressing the reason(s) why you should be considered for this scholarship and also your potential for success in college. - Letter of acceptance from college. - Completed application and required attachments must be mailed or delivered in person by Friday, April 3, 2015 to: Summit Endodontic Specialists, Inc., 3611 Darrow Road, Stow, OH 44224, Attention: Scholarship Committee. PERSONAL INFORMATION & EDUCATION PLANS: Name (First, Middle, Last): _________________________________________________________ Date of Birth: _______________ Address: __________________________________________ City: _________________________ State: ________ Zip: _________ Phone: _________________________ E-mail: _____________________________________________________________________ College you plan to attend: ________________________________________________ City: ___________________ State: _______ Check one: ___4-year college/university ___2-year college/university Have you been accepted? YES / NO Anticipated major: ____________________________________________________________________________________________ ACADEMIC INFORMATION: High School: __________________________________ Anticipated Graduation Date: _____________ Class Rank: _____ of _____ Cumulative GPA: ________ (on a scale of _______) SAT score: _______ out of _______ ACT score: _______ out of _______ Guidance Counselor: ________________________________________ Guidance Counselor’s Phone: _________________________ GENERAL INFORMATION: Father’s Name: ________________________________________ Mother’s Name: ________________________________________ Father’s Occupation: ___________________________ Employer: ____________________________ Length of employment: ______ Mother’s Occupation: ___________________________ Employer: ___________________________ Length of employment: ______ Parents’ marital status (check one): ___Married ___Single ___Separated ___Divorced ___Widowed Ages of siblings and/or step-siblings currently living in household: ______________________________________________________ # of family members living in household: ___ # of college or technical students in your family next year (not including yourself): ___ FINANCIAL INFORMATION: Projected cost of college, not including housing costs or other fees (first year tuition only): ___________________________________ Other scholarships you have received or expect to receive (if known at this time): Name of Scholarship: ____________________________________________________________ Amount: _____________ Name of Scholarship: ____________________________________________________________ Amount: _____________ Name of Scholarship: ____________________________________________________________ Amount: _____________ PERSONAL INVOLVEMENT / ACHIEVEMENTS (Attach additional page if necessary): Extra-curricular activities (list offices held): ________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Sports activities: ______________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Honors/ Awards: _____________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Community/ Volunteer/ Church activities: _________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Work Experience (include dates, position, employer, # of hours per week): _______________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ PERSONAL ESSAY QUESTIONS: Please attach a separate page, typed, double-spaced (maximum of 2 pages), addressing the following two questions: 1) What are your career objectives, and where do you see yourself in five years? 2) How have you made a positive impact in others’ lives? I verify that all information given in this application is true, and I understand that falsification of information will result in the termination of any scholarship granted. Applicant Signature: _________________________________________________________ Date: ____________________________