ST. PATRICK SOCIETY
QUAD-CITIES, U.S.A.
P.O. BOX 4487
DAVENPORT, IOWA 52808
SCHOLARSHIP APPLICATION
(mail to above address)

                                                                                                                                                      _______________
                                                                                                                                                              Date

_____________________________________________________________________________________________________
Name

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Legal Residence

(____)________________ ___________________________ ____________________________________________________
Telephone Number Date of Birth Date of High School Graduation

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Name of School Attending

______________________________________________________________________________________________________
Address of School

References:

               ______________________________________________________________________________________________
               St. Patrick Society Member

                _____________________________________________________________________________________________
                Address

                _____________________________________________________________________________________________
                High School Principal or Guidance Counselor

               _____________________________________________________________________________________________
                 Address

Civic and Community Activities

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

In narrative form, give facts to explain why, in your opinion, you want this scholarship and are qualified to receive if.   (Please use back of this page if necessary.)