PART ONE (QUALIFICATIONS): This scholarship is available to a graduating high school senior or to a currently enrolled college, university, or trade school student whose parent is a North Dakota driver education instructor.  The parent must also be a current and active member of the North Dakota Driver and Traffic Safety Education Association (NDDTSEA).  The scholarship check will be issued to the student and the college/university/trade school at the beginning of the second semester of study.  The application must be submitted one week prior to the NDDTSEA Conference.

NAME:__________________________________________________________________

ADDRESS:___________________________HOME PHONE: ______________________

PARENT'S NAME:________________________________________________________

PARENT'S DRIVER EDUCATION CREDENTIAL #:  _____________________________

HIGH SCHOOL:___________________________________________________________

PARENT'S SIGNATURE:____________________________DATE:__________________

SCHOOL ACTIVITIES                                 COMMUNITY AND CHURCH ACTIVITIES
______________________________          _____________________________________

______________________________          _____________________________________

COLLEGE/UNIVERSITY/TRADE SCHOOL ATTENDING:________________________

FIELD OF STUDY: ________________________________________________________

HOMETOWN NEWSPAPER AND ADDRESS: __________________________________

PART TWO (SCHOLARSHIP):  Completed by high school counselor or principal and/or college/university/trade school advisor.
STANDARDIZED TEST SCORES:_____________________________________________

PSAT STANDARD SCORES:     VERBAL______________      MATH________________

SAT STANDARD SCORES:       VERBAL______________       MATH________________

RANK IN HIGH SCHOOL GRADUATING CLASS ______           CLASS SIZE ________

CURRENT CUMULATIVE GRADE POINT AVERAGE ___________
_____________________________________                                             _____________
Signature of principal/guidance counselor/advisor                                                        date

PART THREE:  Please attach a one-page double-spaced typewritten essay stating why you feel qualified to receive this scholarship and mail along with your completed application to:  Larry Nagel,  HCR1- Box 11, Shields, ND 58569-9723