ENTRY FORM

JOANNE GYURE MEMORIAL SCHOLARSHIP

STUDENT’S NAME:

STUDENT’S HOME ADDRESS:

City: State Zip

Telephone: Social Security Number:

STUDENT’S HIGH SCHOOL:

HIGH SCHOOL ADDRESS:

City: State: Zip:

Telephone:

Student’s signature: Date:

Principal or
Counselor’s signature: Date:

College, university, or other educational institution student plans to attend. (Indicate

name of school and address):

First choice:

Second choice:

The scholarship will be paid on proof of enrollment in the second academic year.