Applicant Information
Name:*
Age:*
Date of birth*
Address:*
Primary Phone:*
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Parent Information
Name of father, step father, guardian:
Father / step father / guardian place of employment:
Father / step father / guardian position title:
Name of mother, step mother, guardian:
Mother / step mother / guardian place of employment:
Mother / step mother / guardian position title:
Other Family Members
Applicant Education Information
High School*
High school address:*
High school telephone number*
-
Graduation date:*
ACT score (most recent)
SAT score (most recent)
High school cumulative GPA*
College / university cumulative GPA (if applicable)
Applicant's school and community activities
List school and community activities in which you participated to a significant degree and to which you made positive contributions.
List any honors or awards you received that are not listed in the previous section.
Applicant's future
What academic program / major or technical program are you considering?*
What do you see as your future occupation / profession?*
References
Please list two (2) references. Examples of references include a principal, headmaster, counselor, teacher, employer, supervisor, or religious leader. Please do not choose a relative.
Applications to colleges, universities, technical schools (skip this step if currently enrolled in higher education).
List, in order of your preference, the names and addresses of colleges, universities, or technical schools to which you have applied. If you have decided which school you will be attending, please mark that school with an asterisk (*) and complete the admission and acceptance information.
Work Experience
List your paid or volunteer work experience (full or part time) including family business experience. If not employed, describe the use of your summer after your junior year.
Company name or employer (1)
Job Description (1)
Dates of employment
-
Hours per week
Pay per hour
Summer only work?
Volunteer work?
Company name or employer (2)
Job Description (2)
Dates of employment (2)
-
Hours per week (2)
Pay per hour (2)
Summer only work? (2)
Volunteer work? (2)
Company name or employer (3)
Job Description (3)
Dates of employment (3)
-
Hours per week (3)
Pay per hour (3)
Summer only work? (3)
Volunteer work? (3)
Essay
In the space below, please write an essay that will help the St. Louis Independent Agents organization better understand you as an individual and your personal goals.
Why do you think you deserve this scholarship from the St. Louis Independent Agents organization?
Conclusion and signature
The St. Louis Independent Agents scholarship fund does not discriminate on the basis of rase, religion, creed, national origin, sex, or condition of handicap in the administration of its scholarship program

Your signature at the end of this application authorizes the St. Louis Independent Agents organization and its selection committee to examine your academic and personal records and to release pertinent data to those involved with the scholarship fund program. Your signature also authorizes the St. Louis Independent Agents organization to verify any information related to your application.

Please verify that all the information in the application is complete and that you have signed the application below. This application must be submitted by April 15th.
Applicant's Signature:*
Typing your name here represents your signature and your acknowledgement of the accuracy of the application information.
Date:*
Information Release
If you are selected to receive an STLIA scholarship, may we recognize your award and use your name on our website and in an email communication to our email subscribers?