PART A:

Name:
                ( please include first, middle initial and last )

Student ID #:

Name of hometown newspaper: 

Local address ( street, city and zip code ):

Local telephone:

Home telephone( please include your area code ):

Home address ( street, city and zip code ):

Academic major:

Academic term:

Expected date of graduation:
                                                      (how many credit hours will be completed at the end of this semester)

Indicate if you are at the Clearfield or main campus:

Please list the name (s) of scholarship (s) for which you are applying:

Should you receive an award: your parents, spouse, guardian or other guest (up to 2) will
be invited to attend the Spring Convocation and lunch. Please provide complete information
so that the letter and invitation can be properly addressed:

1. Name (s) :           
   Number & street:
   City, state & zip: 
    
2. Name (s) :           
   Number & street:
   City, state & zip: 

PART B:

Please answer the following questions:

1.) In 100 words or less, please tell us what your career objectives are:

2.) List the activities which you participated in and contributions you
have made as a student at Lock Haven University ( can be school or community related ):