The Goldfarb Memorial Scholarship

The ARRL Foundation, Inc.
225 Main Street
Newington, CT 06111
foundation@arrl.org

1. Please see the final page for additional instructions. Read thoroughly before completing. The deadline for application is February 1. Scholarships are for the academic year that will commence on or after May 15^th. The blank application form consists of three pages plus one page of additional instructions.

2. Personal Data:

Last________________________________________ First_________________ Middle______________

Birth Date (mm/dd/yy)_____________ Age________ E-mail___________________________________

Home Address___________________________________________ Daytime Phone______________________ ______________________________________________________

City_________________________________________________ State_______ ZIP______________________

3. Schools attended (high school) with most recent first:

School Name and Location	Dates		Degree or Diploma	GPA	Enter GPA Basis (4 pt, 5 pt, 12 pt, 100%, etc.)	Class Standing (X of Y)
School Name and Location	From	To	Degree or Diploma	GPA	Enter GPA Basis (4 pt, 5 pt, 12 pt, 100%, etc.)	Class Standing (X of Y)

4. Student Honors, Awards or Distinctions and Date Received:

__________________________________________________________________________________

5. Community and Extracurricular Activities:

List all community, extracurricular or volunteer activities during last four years. Include dates and/or period of the activity. Include any leadership positions held and dates.

__________________________________________________________________________________

6. Amateur Radio Activities:

Call Sign___________________ License Class_______________ Month/Year First Licensed_______ `

List all ham radio or ham radio related organizations with which you are or have been associated during the last four years. Include dates. Include any leadership positions held and dates.__________________________

__________________________________________________________________________________

Are you or a member of your household currently a member of the ARRL? £ Yes £ No

Describe your current ham radio participations, operating activities, preferences, modes and bands. If not currently participating or operating, explain why.

__________________________________________________________________________________

What role has amateur radio played in your life (attach enclosure if necessary)?__________________

__________________________________________________________________________________

7. Field of Study and Career Intentions:

Major Field of Study:__________________________________________________________________

Career Intentions:____________________________________________________________________

Please explain why you have made these choices (attach enclosure if necessary):________________

__________________________________________________________________________________

8. College or University At Which You Have Applied or Been Accepted:

Name_____________________________________________________________________________

Address____________________________________________________________________________

__________________________________________________________________________________

9. Estimate of Schooling Costs for Next Academic Year:

Please attach a copy of your Student Aid Report (SAR) from your Free Application for Federal Student Aid (FAFSA) request - http://www.fafsa.ed.gov/

Total $_________________

Tuition $___________ Board & Room $__________ Books & Supplies $_________ Misc $__________

10. Funding Sources:

Are you presently or will you be the beneficiary of any other scholarship, grant or stipend? If so, list name of donor(s) and the amount(s) for next year.________________________________________________________

__________________________________________________________________________________

What percentage of your educational expenses is to be paid by:

Family_________ % Yourself_________ % Scholarship or grant__________ % Loan_________ %

11. Your Current Employment (enter None, if applicable):

Employer__________________________________ Type of Work _____________________________

Started There______________________________ Nr Hours Per Week________________________

12. Answer the following questions for individual(s) who claimed you or will claim you as a dependent on the tax return for the calendar year immediately prior to March 15th . If not applicable, enter "none" and see question 13.

Home: £ Rented £ Owned (no loan) £ Being Purchased

Estimated Gross Income:______________________________________________________________

Ages of other household members who are also dependents:_________________________________

13. Answer the following questions ONLY if you were not claimed as a dependent on a tax return for the calendar year immediately prior to March 15th. If not applicable, enter 'none" and see question 12.

Gross Income (include spouse's, if employed):_____________________________________________

Ages of dependent children:____________________________________________________________

14. References:

Please attach letters of reference from three people who know you, including one who is knowledgeable about your educational accomplishments (teacher) and on who knows about your Amateur Radio involvement. Do not include any relatives.

15. Publicity:

If chosen, we'd like to promote your win in your local media. Please provide the name of your local newspaper, television station and radio station.

______________________________________________

16. Testimony and Signature:

I hereby attest that I understand the award terms and that the foregoing information provided by me is true to the best of my knowledge. If I am granted a scholarship by The ARRL Foundation, Inc., I will permit my name to be used for publicity releases to further the aims and purposes of The ARRL Foundation, Inc.

Signature_____________________________________________________ Date_________________

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Application Instructions:

This page is not a part of the application and need not be submitted.
The application and transcript MUST be postmarked during the application filing window of October 1^st to February 1^st. There are no exceptions. All applications or transcripts postmarked prior to October 1^st or after February 1^st will be disqualified.
This scholarship is awarded for the academic year that will begin no earlier than May 15th following the application deadline.
A signed original application and paper copies of all transcripts are required. E-mail submissions will not be accepted.
Transcripts must cover your entire high school career to date.
Letters of reference are required, and should be attached by applicant (no more than three).
Introductory letters from applicants can be attached, but are not required.
If the space provided for your responses is not large enough, you may write "see attached" on the application and include an enclosure or resume. Be sure the enclosure or resume is clearly marked as to the question each portion applies and includes your full name.
Use only one side of the application form. Please do not write on the reverse side. Attach additional sheets as necessary.
The narrative responses to questions 6 (the role of amateur radio) and 7 (why you made these choices) must not exceed one page each.
One of the questions 12 and 13 must have a complete response.
Ranges are acceptable for funding source percentages on application, but you must include the FAFSA or SAR with your application. DO NOT send under separate cover..
Please ensure each entry can be fully understood and appreciated by the members of the ARRL Foundation. For example, indicating membership in Tau Beta Pi does not completely explain the nature of the honor. It would be better to indicate that one was elected to membership in the National Honorary Engineering Fraternity, Tau Beta Pi.
The Goldfarb Memorial Scholarship requires that your field of study must be one of the following: business-related area, computers, medical or nursing, engineering or the sciences. You will not be considered for these scholarships unless your application clearly provides the necessary qualifying information.