American Coalition for Ethanol

Applicant Data

Name*

First Last

Email*

Phone*

Address*

Street Address City State ZIP Code

Date of birth*

Please indicate your status (For statistical purposes only)*

Employee Parent/Guardian Information

I am a*

Member

Employee

Shareholder

Employee of a Company that is a(n):*

Ethanol Producer Member of the American Coalition for Ethanol

Voting Member of the American Coalition for Ethanol

Associate Member of the American Coalition for Ethanol

Member Company Name*

Employee Name*

First Last

Division/ Subsidiary

Relationship to Applicant*

The applicant is a dependent of the member/employee*

Employee Job Title*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Phone*

High School Information

High School Name*

High School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

High School Phone*

High School Graduation Date*

Month and Year

Post-Secondary School Information

What post-secondary school are you attending or planning to attend?*

If unknown, please list in order of preference the schools to which you have applied. Use official School name, no abbreviations.

Type*

4 year College or University

2 year Community or Junior College

Vocational/ Technical School

Other

If "Other", please explain:

Post-Secondary School Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

2nd option (if applicable)

If unknown, please list in order of preference the schools to which you have applied. Use official School name, no abbreviations.

Type

4 year College or University

2 year Community or Junior College

Vocational/ Technical School

Other

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

3rd option (if applicable)

If unknown, please list in order of preference the schools to which you have applied. Use official School name, no abbreviations.

Type

4 year College or University

2 year Community or Junior College

Vocational/ Technical School

Other

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Major or Course of Study*

Degree Sought*

If "Other", please explain

Expected Graduation Date*

Month and Year

Work Experience

Describe your work experience during the past 4 years (e.g. food server, babysitting, lawn mowing, office work). Indicate dates on employment for each, and approximate number of hours worked each week.

Employer and Position

From

Hours per Week

Were you paid for your work?

Employer and Position

From

Hours per Week

Were you paid for your work?

Employer and Position

From

Hours per Week

Were you paid for your work?

Employer and Position

From

Hours per Week

Were you paid for your work?

Activities, Awards and Honors

List all school activities in which you have participated during the past 4 years (e.g. student government, music, sports, etc.) Note all special awards, honors and offices held. Indicate whether these were high school OR college activities.

Activity

Number of years participated

High School or College Activity?

Activity

Number of Years Participated

High School or College Activity?

Activity

Number of Years Participated

High School or College Activity?

Activity

Number of Years Participated

High School or College Activity?

Goals and Aspirations

Make a brief statement or summary of your plans as they relate to your educational and career objectives and long-term goals.*

Unusual Circumstances

Please describe how and when any unusual family or personal circumstances have affected your achievment in school, work, or your participation in school and community activities.

Three (3) $1,000 Scholarships!