A Registered 501(c)3 Public Charity Start A Fund Manage A Fund Scott Roberson Scholarship Personal Information Full Name DOB (dd/mm/yyyy) Address City State —Please choose an option—AL AlabamaAK AlaskaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFL FloridaGA GeorgiaHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaOH OhioOK OklahomaOR OregonPA PennsylvaniaRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming Your Email Education High School Name High School City High School State High School Graduation Date College Name College City College State Community Involvement List in order of importance to you. Organization Name Dates From: To: Position Duties (50 Words) Organization Name Dates of Employment From: To: Position Duties (50 Words) Organization Name Dates of Employment From: To: Position Duties (50 Words) Essay Please write an essay in the space below (not to exceed 1000 words) that describes the positive impact you have made in your community and how you intend to continue your community service (in Tolland or other areas) as you start your college education. Declaration By inputting your name below you certify that all the information provided in this application is accurate to the best of your ability. Name Date