Citizens Bank of West Virginia

Citizens Scholar Awards

INDENTIFICATION

First Name	Last Name	Middle Name




Street	City	State	Zip




Email Address	Telephone	Place of Birth




Will You Be Attending a WV College or School?		Yes No



Date of Birth		Social Security Number
(mm/dd/yyyy)



Name & Address of Parent or Guardian




EDUCATION
High school(s) attended: list in chronological order all schools attended during the last two years:

Name of School	Location


Course of Study	Dates of Attendance
	From: To:



Name of School	Location


Course of Study	Dates of Attendance
	From: To:



SAT/ACT Score	Cumulative GPA	# Of Honors Classes




College(s) or school(s) to which you have applied for admission:

Name of School	Location


Field of Study	Have You Been Accepted?
	Yes No



Name of School	Location


Field of Study	Have You Been Accepted?
	Yes No



HONORS & ACTIVITIES

List any Scholastic Honors & Awards you have received while in High School:


List all extra-curricular activities in which you have participated, including but not limited to scholastic, cultural, athletic, civic or community activities:




WHY YOU SHOULD RECEIVE A CITIZENS SCHOLAR AWARD

Please reply to the following statement. Your answer should be limited to no more than 250 words (double-spaced). Tell us why Citizens National Bank should designate one of the Citizens Scholar Awards to you.




STATEMENT OF UNDERSTANDING

By checking the box below, I certify that everything I have stated and reported in this application is correct to the best of my knowledge at this time. I understand that Citizens National Bank of Elkins will retain this application and its enclosures whether or not I am successful in receiving a scholarship. I further agree that the decision of the Citizens National Bank Scholarship Selection Committee will be final. Yes, I Agree to the above Statement of Understanding Today's Date: 09/09/2010

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