Membership Application
Alpha of Clovia 4-H Scholarship House
Kansas State University

I. Personal Data

Name______________________________________________
Home Address:___________________________________

City: _______________________ St:_____Zip:__________

County:_________________________________________

Home Phone:(______)_____________________________

School Address:__________________________________

School Phone:(______)____________________________

Age:__________________Birth date:_________________

Parents or Guardians:______________________________

Address:________________________________________

City:_________________________ St:______ Zip:_______

Mother's Occupation:_______________________________

Father's Occupation:________________________________

Number in Family: Brothers _________ Sisters____________

II. 4-H Work

Explain briefly which 4-H experiences have been of greatest value to you, and tell why.

III. High School Record

Name of high school attended:__________________________________________
Date of graduation:_____________________ G.P.A.:_______________________
Your rank in class:______________________ Number in class:________________

List work experience and job responsibilities:

Explain church and community activities you have participated in:

Describe your main hobbies and interests:

IV. College Record

What do you plan to major in at Kansas State?
First choice:_______________ Second choice:____________________


Have you attended college previously? o Yes o No

If so,where?___________________________________ GPA:___________

Classification:___________________ Major:_________________________

V. Alpha of Clovia

Why do you want to be a member of a cooperative scholarship house?

What factor influenced you to consider Clovia?

VI. References

Name:________________________________________
Address:______________________________________
Occupation:____________________________________



Name:________________________________________
Address:______________________________________
Occupation:___________________________________



Name:________________________________________
Address:______________________________________
Occupation:___________________________________





VII. Membership Application

To be accepted to Alpha of Clovia, Kansas State University's 4-H scholarship house, an applicant must:
1. Complete written application
2. Send three letters of reference
3. Attend personal interview