The Peggy Perry Belcher Scholarship Fund, Inc Scholarship Application Name* First Last Phone Number*Mailing Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Name* First Last Email Address* High School or College GPACollege or University plan to attend or currently attendingTelephone Number of college or universityMajorMinorHow will this scholarship influence your life?Church, Community and Volunteer Service and Extra-Curricular ActivitiesList participation in church, community and volunteer service and/or extra-curricular activities during your high school and/or college years, if applicable. Honors and AwardsList any honors and awards received during your high school and/or college years, if applicable. I certify that the information contained herein is true and correct to the best of my knowledge. If I am an award recipient, I give the Peggy Perry Belcher Scholarship Fund, Inc. Board of Directors and affiliates the right to use my name and picture to announce and advertise in media and social media outlets. Applicants, scholarship recipients, parents and affiliates waive any right to payment, royalties or any other consideration for the use of the images. We further hold harmless Peggy Perry Belcher Scholarship Fund, Board of Directors and affiliates of any written or print information on the applicant and/or scholarship recipient. Signature of Applicant & DateUpload Supporting Documents* Drop files here or Accepted file types: jpg, pdf, png, doc.