ALBANY ROUNDTABLE

CIVIC LUNCHEON SERIES

PO. BOX 7101 - ALBANY, NY 12224 - FOUNDED 1979
WWW.ALBANYROUNDTABLE.COM

The Albany Roundtable is offering a One Thousand ($1,000) Dollar Scholarship

to a high school senior who is recommended by a member in good standing of
the Albany Roundtable.

THIS APPLICATION IS TO BE SUBMITTED BY A STUDENT IN HIS/HER

SENIOR YEAR OF HIGH SCHOOL. THIS SCHOLARSHIP IS CONTINGENT
UPON ACCEPTANCE AND ATTENDANCE AT A TWO (2) OR FOUR (4) YEAR
COLLEGE OR UNIVERSITY.

DIRECTIONS: Complete this questionnaire and return to the above address with
a postmark or email to ecrosen52@gmail.com no later than March 31, 2018.
Please print or type all information.

Please include the following:

 A letter of recommendation by a teacher/counselor from the applicant’s

school, or if home schooled, from a member of the community.
 An official transcript containing courses, grades and school average.
 An essay of 300-500 words on the following topic:

Citizenship includes the exercise of certain personal

responsibilities, including considering the rights and interests of
others. Discuss your involvement in a civic capacity which
demonstrates your commitment to the community. This can
include religious, social and/or political activities.

Date:____________________________________________________________

Name of
Applicant:________________________________________________________

Address:_________________________________________________________

Phone:_____________________________

Email address:____________________________________________________

High School Date of Graduation:______________________________________

-OVER-
College to which you are applying:_____________________________________

Second choice:____________________________________________________

Major (if known):___________________________________________________

If already accepted, indicate school and date of acceptance:

________________________________________________________________

Name of
Parent:__________________________________________________________

Address:_________________________________________________________

Phone:_______________________email address:________________________

I certify that all the information on this form is true and completed to the
best of my knowledge. I have completed the application with the consent
of a parent/guardian but have not received assistance from them in writing
the essay.

Applicant’s
Signature:__________________________Date:_______________________

Parent’s
Signature:__________________________Date:_______________________

Roundtable
Sponsor:___________________________Date:_______________________