Mr. Henry Gay Sr. Scholarship Application Form

Bloomington-Normal Branch l P.O. Box 925 l Normal, IL 61761-0925 l 1.866.881.9848

Mr. Henry Gay Sr. Scholarship Application

The application must be typed or printed clearly.  If additional pages are needed, please attach the additional pages to this application form.  Submit all required items: application, transcript, letters of recommendation, college/university acceptance letter, and essay.  Send to NAACP; Attn:  Scholarship Committee; P.O Box 0925; Normal, IL 61761 postmarked no later than Friday, May 5, 2017.  Questions about the scholarship or application process may be directed to Ben Ryburn, Scholarship Committee Chair at

  1. Application Information


Last Name                     First Name                        MI                                          Date of Birth


Address                                             Apt. #                     City                        State       Zip


Telephone Number                     Email Address                       Name of High School Attending

  1. Parent/Guardian Information


Last Name                           First Name                             MI


Address if different from above

  Extracurricular activities in school, community, and church. Include any special honors, awards.



 College/University you plan to attend. Please provide letter of acceptance or other pertinent information.


How did you become aware of this scholarship?  School_____Church_____Other____________

 I hereby certify that all of the above information is true and correct and that any misrepresentation or omission of facts on my part will be justification for denial of this scholarship.  I understand that the funds must be used for educational purposes, i.e., tuition, housing, books and/or supplies during the 2017-2018 academic terms.  I also understand that all information provided is confidential and will only be released to the NAACP Scholarship Committee in conjunction with the scholarship program.


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Applicant’s Signature                                       Date

Parent/Guardian Signature                              Date

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