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Scholarship Application

The application must be completed in full. Full is defined as completing all application questions including all document uploads (even the official transcript).

You will not be able to come back and edit this form. Please do not fill it out until you have all of the requested information available.

Fields marked with an * are required.

APPLICATION INFORMATION

Have you read through all the steps in the Application Process tab?*

Yes No
Last Name: *
First Name: *
M.I.:
Address: *
Apt. No. / Unit No.:
City: *
State: *
Zip Code: *
Phone: *
Email Address: *
Did you graduate form PHCC?*

Yes No

If so, when?*
Are you affiliated with Carter Bank & Trust as an employee or child of an employee?*

Yes No

If so, provide branch/employee name?*
Have you previously received a Foundation scholarship?*

Yes No

If so, when?*
Are you currently enrolled in, admitted to or applied to an NCI program?*

Yes No

If so, which?*

EDUCATION

High School Name:*

Address:*

From:*

To:*

Did you graduate?* Yes No

Diploma:*

GPA:*
College Name:*

Address:*

From:*

To:*

Did you graduate?* Yes No

Diploma:*

GPA:*
Other School Name:

Address:

From:

To:

Did you graduate? Yes No

Diploma:

GPA:

EMPLOYMENT HISTORY

Company Name:*

Phone:*

Address:*

Supervisor:*

Job Title:*

From:*

To: Present Employer
Company Name:

Phone:

Address:

Supervisor:

Job Title:

From:

To: Present Employer
Company Name:

Phone:

Address:

Supervisor:

Job Title:

From:

To: Present Employer

COMMUNITY SERVICE

Organization:*

Role:*

From:*

To:*
Organization:

Role:

From:

To:
Organization:

Role:

From:

To:

PERSONAL STATEMENTS

Complete each in two to three paragraphs, not to exceed 250 words.
What field of study have you chosen and why?*
Describe a leadership role you have held and explain how the experience impacted your life?*

Other (Optional) Other information you would like the scholarship committee to consider when reviewing your application.

Document Upload

Community Service Verification: *
Letter of Recommendation 1: *
Letter of Recommendation 2: *
Photo: *
Official Transcripts: *

ATTESTATION AND SIGNATURE

I certify that the information provided in my application is complete and accurate to the best of my knowledge and any significant false statements on this application will disqualify me from receiving a scholarship.
I understand that my application is not considered complete without an official college transcript, two letters of reference from individuals unrelated to me, a signed community service verification form and a personal photo.
I understand that I must be admitted, at the time of this application and disbursement of any funds, in a New College Institute (NCI) affiliated program pursuing a bachelor’s degree, graduate degree, endorsement graduate certificate, or post-graduate degree to receive funds.
I understand that I must adhere to all deadlines for my application to be considered and for funds to be released.
I acknowledge that any funds received must be used for enrollment in NCI programs and will be paid directly to the partner institution.
I understand that the disbursement of scholarship funds is contingent upon me writing a professional appearing thank you note to the scholarship donor(s).
I give permission to use my photograph and any general non-financial information included in this application for publicity purposes.
I give permission to the colleges or universities I have attended to release any information necessary to review my application.
I understand that MHC Academic Foundation will securely maintain my contact information for future correspondence.
Signature: *

Please type in verification code *

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MHC Academic Foundation
PO Box 492
Martinsville, VA 24114
276.403.4445