DEADLINE:    TO BE RETURNED BY APRIL 1

SCHOLARSHIP APPLICATION FORM:
Merlin & Ethyl Rufer Scholarship Trust - Fort Dodge, Iowa

Part I:  Resume:

Name of Candidate: _____________________________________________________________________
                                                                (Last)                                        (First)                                      (Middle)

Home Address: _________________________________________________________________________
                                                (Street)                                    (City/Town)                                             (Zip Code)

Telephone #: ______________________________________ Social Security #: ______________________

Email Address: _________________________________________________________________________

Name of High School: ___________________________________________________________________

Name of Iowa College/University Admitting Candidate: ________________________________________

Registrar’s Phone # and  Address:
______________________________________________________________________________________
(phone #)                                 (Street)                                    (City/Town)                                             (Zip Code)

Candidate's Intended Major Area of Study: ___________________________________________________

Candidate's Academic Status:           Cumulative G.P.A.                                _______________
                                                                A.C.T. Percentile                                  _______________
                                                                A.C.T. Composite                                _______________

Part II:  Family Status:

Name of Father (if living): ________________________________________________________________

Name of Mother (if living): _______________________________________________________________

Address (if different from Candidate's):  _____________________________________________________

Occupation of Father: ____________________________________________________________________

Occupation of Mother: ___________________________________________________________________

Total Annual Income of Parents: ___________________________________________________________

Number of children still being supported and living at home:    _______________

Note:   If candidate is under the care of a guardian, please indicate name, address and occupation of same by simply crossing out "Father" and "Mother" and entering "Guardian".

                                                                                                                                                Page 2 of 2

Part III:  Candidate's Estimated Sources of Financial Support for Initial Year of College:

Iowa Tuition Grant Program:              $______________________________________________
Social Security Benefits:                     $______________________________________________
Personal Savings:                                $______________________________________________
Parental Support:                                 $______________________________________________
College Employment:           $______________________________________________
Other (Specify):                                    $______________________________________________

NDSL:                    $______________________________________________
SEOG:                     $______________________________________________
BEOG:                    $______________________________________________

Total:                      _______________________________________________

Part IV:  (For use by College/University student who has previously been awarded the  Merlin & Ethyl Rufer Scholarship):

Name of College Currently Attending: _______________________________________________________

Year in College: ________________________________________________________________________

Grade Point Average as of this Date: ________________________________________________________

List any Additional Necessary Information: ___________________________________________________

______________________________________________________________________________________

Part V:  Additional Data Including Extracurricular Activities -- (Please attach):

   NOTE:   I understand that this application is not complete unless there is:
                1)  A letter from my Superintendent/Principal  or  College/University Academic Advisor
                2)  A personal request and resume both in support of this application.

Date: ______________________ Signature of Applicant:  _______________________________________

Part VI:   Please drop off, mail, or email this completed application to me no later  
                       than April 1st.

         Dan Brown                                                                    Thank you,
         343 Loomis Ave.
         Fort Dodge, Iowa  50501                                                                            Daniel D. Brown
            Phone: (515)573-3452                                                                               Member of Ashlar Lodge #111
            Email:  dand1@frontiernet.net
                      (it is a #1 after 'dand' above)