Jay Elmore Memorial Scholarship
Official Application

Please complete this application in its entirety.  Include any attachments necessary, including a copy of your most recent high school transcript, and a letter of recommendation from at least one high school principal, guidance counselor, teacher, or church leader.  All scholarship applicants must be seniors in high school.  Please return the application no later than January 1, 2011 to:

Coca-Cola Jr. Tour
P.O. Box 381
Belden, MS 38826

STUDENT INFORMATION
Name: ____________________________________  Date of Birth: _________________
Address: ________________________________________________________________        
________________________________________________________________
Phone: ________________________  Social Security #: __________________________

High School Information

High School Attended: ____________________________________________________
Address: ________________________________________________________________
________________________________________________________________
Latest Cumulative GPA: __________________  Rank/Class Size: __________________
ACT: __________  SAT: __________

College Information

College you hope to attend: _________________________________________________
Address: ________________________________________________________________
________________________________________________________________
Date entering as a full time student: __________________________________________
Probable Major: _________________________


EXTRA CURRICULAR ACTIVITIES:

Please list your extra curricular activities under the proper section.  You may attach an additional sheet if more space is needed.

School Related Club and Activities:










Interscholastic Athletics:










Non-school Related Clubs and Activities:










Honors and Awards: