Student Name (First, Middle, Last)
Student Address
Student City
Student State and Zip Code
Student Email:
Phone (Home)
Phone (Cell)
High school attended
Reference #1 name and title: High school academic achievements reference (administrator, teacher, or guidance counselor)
How do you know Reference #1?
Reference #1 phone number
Reference #2 name and title: Community leader who has personal knowledge of your community activities and participation
How do you know Reference #2?
Reference #2 phone number
Reference #3 name and title: Teacher, adviser/coach, or employer who can attest to your leadership and entrepreneurial potential
How do you know Reference #3?
Reference #3 phone number
List your most notable activities, work, and community service experience. (Please type no less than 5 achievements in a Word document and then copy and paste it into the box.)

By clicking on the "Submit Form" button below, I certify that I am a resident of Schuylkill County, and do hereby apply for the Wylonis Scholarship Award for the 2014-2015 academic year. I fully understand that any scholarship granted to me is not a vested right binding upon the donor or the Pennsylvania State University, and that the scholarship may be revoked should I fail to continue as a student at the Pennsylvania State University or fail to continue to meet the standards established for this scholarship program.

By clicking on the "Submit Form" button below, I confirm the accuracy of the information contained herein as well as my understanding of the conditions of this scholarship program and my acceptance of them.

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