Select scholarship type:



 



 2015 “The use of tobacco in religious rituals throughout history” Scholarship



 2015 “Cigar culture in America” Scholarship



 



Personal Information



Please attach a yearbook-style picture of yourself to this application for publicity purposes.



 



Name_________________________________________________________________________________________



High School (if in grade 12)_______________________________________________________________________



City and County_________________________________________________________________________________



Home Address__________________________________________________________________________________



City_________________________________________ State________________________ Zip Code_____________



Home Phone Number______________________________ Mobile Phone Number___________________________



Email Address__________________________________________________________ Gender:   Male  Female



Weighted GPA_______________ Class Rank:__________ of ____________ total students



SAT or ACT Scores: V______________ M_______________ W______________ Combined_____________________



Intended Major_________________________________________________________________________________



College/University attending or planning to attend_____________________________________________________



If undecided, list any colleges or universities applied to or accepted_______________________________________



List of all scholarships applied for and the status_______________________________________________________



_____________________________________________________________________________________________



_____________________________________________________________________________________________



 



Mother’s Name or Legal Guardian__________________________________________________________________



Home Address__________________________________________________________________________________



City, State, Zip Code_____________________________________________________________________________



Home Phone____________________________________ Mobile Phone___________________________________



Email Address__________________________________________________________________________________



Employer_______________________________________ Occupation_____________________________________



Father’s Name or Legal Guardian___________________________________________________________________



Home Address__________________________________________________________________________________



City, State, Zip Code_____________________________________________________________________________



Home Phone____________________________________ Mobile Phone___________________________________



Email Address__________________________________________________________________________________



Employer_______________________________________ Occupation_____________________________________



 



Please list any circumstances that may affect your ability to pay for college:_________________________________



_____________________________________________________________________________________________



_____________________________________________________________________________________________



 



Referral Information



How did you hear about the Serious Cigars Scholarship Program? ________________________________________



_____________________________________________________________________________________________



Extracurricular Activities



Sports, clubs, volunteer work, fine arts, scouting, jobs, church involvement, hobbies, internships and special interests.



 




































ACTIVITY

YEARS PARTICIPATED

HOURS PER WEEK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 



By signing below, I certify that the information provided in this application is accurate and complete to the best of my knowledge. I understand that falsification of any information will result in termination of any scholarship granted. I also understand that incomplete or late applications will not be considered for this scholarship. In the event that I receive the Serious Cigars 2015 Scholarship, I permit the company to use my presentation, name and likeness in publicity materials relating to the scholarship.



 



_________________________________________________________



Signature of Applicant



 



 



_________________________________________________________



Signature of Parent or Guardian (if applicant is a minor)



 



 



_________________________________________________________



Date of Application



 



Submit your application and supporting documents by U.S. mail to: 



Serious Cigars - Scholarship

ATTN: Ron Lesseraux

6608 FM 1960 W. Suite D

Houston, Texas, 77069



 



Release form for Participants





To be completed by all visible AND/OR audible participants in the video:





By signing below, I authorize (applicant name)____________________________to publicly share my likeness, voice and on- or off-camera performance with Serious Cigars for the purpose of his or her 2015 scholarship entry. I further authorize Serious Cigars to publicize the entry at will, including but not limited to social media outlets, the company’s website, and promotional materials. I agree to hold Serious Cigars and its employees harmless from any liability related to the scholarship contest or the award process.



 




























































             NAME             

             SIGNATURE             

GUARDIAN SIGNATURE

(if minor child)

          DATE          

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 








POSTED ON Oct 14, 2017

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