ARKANSAS STATE UNIVERSITY

DEPARTMENT OF COMMUNICATION

ARTHUR RAY "KIP" MOORE & MARY SUE MOORE MEMORIAL

SCHOLARSHIP APPLICATION

School Year 20____ - 20____

(Please Print or Type)

NAME __________________________ SOCIAL SECURITY NUMBER ______________

HOME ADDRESS__________________________________________________________
(Street)	(City)	(State)	
CAMPUS ADDRESS  _________________ __________________________ ___________	
(Street)	(City)	(State)	
HOME TELEPHONE NO. _____________ ASU TELEPHONE NO. __________________

HIGH SCHOOL ATTENDED __________ ______________________________________

DATE OF BIRTH ______________________   MALE_________ FEMALE _________

CAREER CHOICE _____________________   COLLEGE MAJOR  __  ___________ _

If this application based on financial need?	YES _________ NO

Have you applied for other financial aid?	YES _________ NO
If yes, state what other aid. (work-study, general scholarship, etc.

___________________________________________________________________________

What income sources do you have available to meet expenses during this school year?

___________________________________	$_________________________

______________________________	$_____________________

Will you be employed while attending ASU?	________  YES __________NO
Father's Name _______________________	Employer ___________________________

Mother’s Name_______________________	Employer____________________________

____________________________________________________________________________

Remarks: Add any other information that you feel would help the committee in evaluating you request.

_________________________________________________________________________

_________________________________________________________________________

GPA ________________

What area of Communication are you interested in? __________________________________

____________________________________________________________________________

I HEREBY CERTIFY THAT THIS INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
_______________________________

Applicant's Signature

CONFIDENTIAL INFORMATION

Deadline: February 1, 2014