Deadline: March 31
Return application to the Foundation office, PO Box 462, Louisa, Va. 23093.
1. Personal Information
Name: _________________________________________________________________
(First) (Middle) (Last)
Address: ______________________________________________________________
_______________________________________________________________________
County of residence: _____________________________________________
What school do you attend? _______________________________________
What grade level? ________________________________________
Social Security Number: ____________________________________________
Phone number:___________________________ E-mail:____________________
Father’s name: ___________________________ Occupation: ___________________
Employer: ______________________
Mother’s name: ____________________________ Occupation: ___________________
Employer: ______________________
Number of family dependents:______________________(Do not include parents)
Annual combined family income: _____________________________________
Number of dependents who will be in college this school year: ____________________
Expected expenses of applicant (tuition, room & board):__________________________
What college do you plan to attend? _________________________________________
Have you been accepted? ________________________________________________
1. Grade point average (attach transcript)_______________________________________
2. SAT scores (attach report)_______________________________________________
3. On a separate sheet of paper, please answer the following questions. Responses to each
question should be approximately one-half page in length. Please put your name on the
top of each page.
a) What are your educational goals?
b) What are your personal goals?
c) Why do you need financial assistance?
d) Is there any other information that you think might be helpful for the selection committee?
(honors, certificates, special circumstances other than financial, community service work)
4. Attach a letter of recommendation attesting to moral character.
If I am selected as a recipient, I hereby give permission to the William A. Cooke Foundation
to use my name. picture, narrative, and the fact that I was awarded a scholarship for promotional
purposes.
I certify the information contained in this application and any accompanying documents is true,
complete, and correct to the best of my knowledge.
Signature: ___________________________________ Date: ______________________
Please send your application and/or related material, as follows:
William A. Cooke Foundation
P.O. Box 462
Louisa, Virginia 23093