The Long Trust Health Care Scholarship
Becker and Norman County Residents
Application Deadline: January 15th
					
Send to:  	D. L. Area Community Foundation (Do Not Return to City Hall)
	    	P.O. Box 1340
	    	Detroit Lakes, MN 56502-1340	    

NAME___________________________________________________________________
		Last			First		     Middle

ADDRESS________________________________________________________________
		Street		City		State		Zip
e-mail________________________________________Phone #__________________

DATE OF BIRTH_____________________SEX__________MARITAL STATUS__________

LENGTH OF RESIDENCY OF SELF OR FAMILY IN BECKER OR NORMAN CO.?_________
(or within a thirty mile radius of Detroit Lakes or Ada)

Please give the school, and program enrolled in, to which this
scholarship would apply:

SCHOOL_________________________________________________________________

ADDRESS________________________________________________________________

CITY/STATE________________________________________________ZIP__________

PROGRAM/COURSE NAME____________________________________________________
		(Please enclose an official transcript of grade records and GPA.) 

How long will this course take? ____________________________

What is the date of your expected completion of it? ___________________

Itemize your yearly expenses (tuition, living expenses, books, etc.)










List your yearly sources and amounts of financial income/aid
(scholarships, loans, personal resources.)











REFERENCES:  Please attach three letters of recommendation to this
form.  At least one from an academic source, one from a community or
job source.

	NAME		POSITION		ADDRESS				PHONE

1._____________________________________________________________________

2._____________________________________________________________________

3._____________________________________________________________________


EDUCATIONAL BACKGROUND: 
	Please enclose an official transcript of grade records and GPA from the
	following:

1.  HIGH SCHOOL ATTENDED

Name of School_________________________________________________________

Address________________________________________________________________

Year Graduated__________________	G.P.A._________________

Special awards, Honors and Scholarships received





School activities, special interests, Offices or positions held




 2.  COLLEGE OR VOCATIONAL SCHOOLS ATTENDED:
	
* Name of Institution__________________________________________________

	Address________________________________________________________

	Years attended__________G.P.A._________Year graduated__________

	
* Name of Institution__________________________________________________

	Address________________________________________________________

	Years attended__________G.P.A._________Year graduated__________


*	Special awards, Honors, and Scholarships received






OTHER ACTIVITIES  (Community, extra-curricular, or volunteer)  
	Please indicate any positions held or honors received.




	Leisure time interests and hobbies





JOB EXPERIENCE/EMPLOYMENT RECORD:  List employer, dates of employment,
and job title starting with most recent position.






Write a statement as to why you chose your field of study, and what
you intend to do when you have completed your training.







Tell us why you feel you should receive this scholarship.






Any other pertinent information about yourself that we should know.




I certify that all information on this application is accurate and
complete.


Signed_______________________________________________Date______________
		Applicant

Application Deadline: January 15
Send to:	D. L. Area Community Foundation
			P. O. Box 1340
			Detroit Lakes, MN 56502

Administered by the Detroit Lakes Area Community Foundation a
subsidiary of West Central MN Initiative Fund, 1000 Western Avenue,
Fergus Falls, MN 56537.