The larry a

THE LARRY A. HART MEMORIAL SCHOLARSHIP

INFORMATION TO APPLICANT

To honor the memory of Wildlife Officer/Field Supervisor Larry A. Hart, the Ohio Wildlife Officers' Fraternal Order of Police, Lodge #143, and the Twin Valley Rod & Gun Club have established the Larry A. Hart Memorial Scholarship. Officer Hart's thirty-year legacy of integrity and commitment to the profession of Wildlife Management and Law Enforcement set a timeless standard for all future officers. Additional information is as follows:
1. TYPE OF SCHOLARSHIP: This is a one-year scholarship in the amount of one thousand dollars. Payment of the scholarship will be made directly to the Bursar of the college where the recipient is or will be attending.
2. WHO MAY APPLY?

A. Any person who is an Ohio resident;

B. Any person who has or will be graduated from an accredited high school;

C. Any person who is or will be enrolled in an accredited college and will be pursuing

a career in the field of law enforcement, or natural resources.
3. WHAT ARE THE REQUIREMENTS?

A. GOAL - The applicant shall have a desire to pursue a career in the field(s) of law

enforcement and/or protection or management of natural resources.
B. INTEREST - The applicant must have a serious interest in advancing his or her

education in natural resources and/or law enforcement studies.

C. SELECTION OF INSTITUTION - The recipient of this scholarship must choose to

attend an accredited institution, be it college, university, or technical

college.
D. ATTITUDES AND ACTIVITIES - The applicant shall demonstrate the upstanding

character and positive personal attributes necessary for becoming a

successful public servant through his or her participation in

extracurricular activities, such as church and/or other community

service.
4. THE APPLICATION: It is important that all requested information be supplied

promptly in a neat, accurate, and honest format. Do not hesitate to add additional sheets

when necessary. Also, the attached Recommendation for Scholarship form must be

completed by two references (no relatives, please), and returned to: The Larry A. Hart

Memorial Scholarship Committee, 174 Briarwood Drive, Mount Vernon, Ohio 43050.
5. DUE DATE FOR ALL DOCUMENTS: The Larry A. Hart Scholarship Committee

shall receive ALL documents pertinent to your application on or before the 15^thof March.
6. The recipient of this scholarship will be required to submit a suitable photograph, that

may accompany the news release.

Page 1

THE LARRY A. HART MEMORIAL SCHOLARSHIP APPLICATION

(Revised 01/2016)

Applicant, be sure to thoroughly complete this form and return it, along with your two letters of recommendation, to the committee on or before the 15^th day of March. Please answer all of the questions carefully, with honest and accurate detail. Feel free to add extra sheets for any additional information you wish to include.
SECTION 1 - PERSONAL INFORMATION
1. Name: _____________________________________________________________________
2. Home Address: ______________________________________________________________
3. Home Phone #: (____) __________________ Cell Phone #: (____) ___________________
4. College Address: _____________________________________________________________
5. College Phone #: (___) __________________Other Contact #: (____) _________________
6. E-mail address: ______________________________________________________________
7. Other Information: Age: ________Date of Birth: ____/_____/______
Last 4 digits of your S.S.N.: ________ Place of Birth: ___________________________
8. Are you a Veteran or currently serving in a branch of the armed forces? _____________
If yes, what branch?_________________________________________________________
Who is your Commanding Officer? _____________________________________________
9. Have you successfully completed a Hunter Education Course? ______________________

If yes: State ________________ Year _____________
9A. Have you successfully completed a Trapper Education Course? ____________________

If yes: State ________________ Year _____________
10. Do you currently participate in any type of shooting sports? ______________________

If yes, what type?__________________________________________________________
11. Are you a member of Ducks Unlimited, National Wild Turkey Federation, Pheasants

Forever, the National Rifle Association or any other type of conservation organization?

If yes, name the organization(s): ______________________________________________
11A. Are you now, or have you ever been involved in a scouting type organization? _______

If yes, what is the name the scouting organization: _______________________________
12. How did you find out about this scholarship? ____________________________________
Page 2

SECTION 1 - PERSONAL INFORMATION (Continued)
13. Please describe all important activities, honors, awards, scholarship ratings or any other forms of recognition that you have received from your community, school, college, church, etc.:__________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________
14. Describe your feelings about managing wildlife resources by hunting and/or trapping: ______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________
15. What are your hobbies: ______________________________________________________

______________________________________________________________________________

______________________________________________________________________________
16. Please describe your involvement with law enforcement (if any):____________________

______________________________________________________________________________

______________________________________________________________________________
17. Can you describe your involvement with a natural resources agency (if any): _________

______________________________________________________________________________

______________________________________________________________________________
18. What type of position/career are you striving to attain? Why?______________________

____________________________________________________________________________________________________________________________________________________________
19. Are you a resident of Ohio? (Note: For this scholarship, you must reside in Ohio within

the last six months. (Students who live in Ohio, but go to college out-of-state qualify as

residents) [ ] Yes [ ] No
SECTION 2 - HIGH SCHOOL ACADEMIC ACHIEVEMENT
20. You have/will graduate(d) from what high school?________________________________
21. High school address:________________________________________________________
22. High school phone number: (____) ____________________________________________
23. What year will/did you graduate from high school? _______________________________
24. Attach a copy of your high school transcript to your application package -OR- On a separate sheet of paper, list all of the courses that you have taken during your Freshman, Sophomore, Junior, and Senior years in High School, with grades/G.P.A. for each subject.
Page 3

SECTION 2 - HIGH SCHOOL ACADEMIC ACHIEVEMENT (Continued)
25. "Attachment A" has been completed by the high school administrator? [ ] Yes [ ] No

SECTION 3 - COLLEGIATE ACADEMIC ACHIEVEMENT
26. Attach a copy of your college transcript to your application package -OR- On a separate sheet of paper, list all of the courses that you have taken during your Freshman, Sophomore, Junior, and Senior year(s) in college, with grades/G.P.A. for each subject.
27. "Attachment B" has been completed by the College Registrar? [ ] Yes [ ] No
28. Are you currently enrolled in college?

[ ] Yes (Go to question # 28A) [ ] No (Go to question # 29)
28A. In what college are you currently enrolled? ____________________________________

The address of the college is: ________________________________________________
28B. What is your college major and minor? _______________________________________
______________________________________________________________________________
29. What college are you planning to attend? _______________________________________

The address of the college is: __________________________________________________
29A. What will your major and minor be? _________________________________________

______________________________________________________________________________
30. How much is your college education going to cost this school year? $_________________
SECTION 4 -FAMILY/FINANCIAL
31. Name of Parent(s)/Guardian(s): _______________________________________________

______________________________________________________________________________
32. Address and Phone Number of Parent(s)/Guardian(s): ____________________________

______________________________________________________________________________
33. Family information:
A. Father: Living? [ ] Yes [ ] No [ ] Unknown
Current Occupation; _____________________________________________

B. Mother: Living? [ ] Yes [ ] No [ ] Unknown

Current Occupation; ______________________________________________
C. Guardian(s): Living? [ ] Yes [ ] No [ ] Unknown

Current Occupation; ______________________________________________
Page 4
SECTION 4 - FAMILY/FINANCIAL (Continued)

D. If you are living with a guardian, what relationship do you bear to the person you have

indicated as your guardian? _________________________________________________
E. Number of siblings: Living at home?

Older Sisters: _________ [ ] Yes [ ] No

Younger Sisters: _________ [ ] Yes [ ] No

Older Brothers: _________ [ ] Yes [ ] No

Younger Brothers: _________ [ ] Yes [ ] No
34. Are you dependent upon your parents for support? [ ] Yes (See 34A) [ ] No
A. How many persons are dependent upon your parent(s)/guardian for support? ______

35. Your marital status is (Circle One): Single Married Divorced Separated Widowed
36. Do you have any dependants? [ ] Yes, The number of dependants:_____ [ ] No
37. How much financial aid during the next year do you expect to receive from your

parents/guardian? Explain fully: ________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________
38. Please list any other sources of financial aid that you will be receiving during the next school year: ___________________________________________________________________

____________________________________________________________________________________________________________________________________________________________
39. Do you have any special financial needs? ________________________________________

______________________________________________________________________________

______________________________________________________________________________
SECTION 5 - OTHER INFORMATION
40. Is there any other information that you would like the Scholarship Committee to consider? [ ] No [ ] Yes: ______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
The above statements, and documents attached, are correct and true to the best of my knowledge. I hereby agree that if I become the recipient of this scholarship, I shall abide by the regulations and provisions under which the same are granted.
Date: ___/___/___ Signature of the Applicant: ___________________________________
Page 5

THE LARRY A. HART MEMORIAL SCHOLARSHIP
ATTACHMENT A - HIGH SCHOOL TRANSCRIPT SUPPLEMENT
If the following information is not listed on your high school transcripts, please have the appropriate high school administrator complete the following information:
This is to certify that the applicant, ____________________________ will be/has
graduated from ________________________________________ High School, located at
______________________________________________________________________________.
The applicant will/has graduate(d) on ____/____/____, and has/had a cumulative grade point average of ___________________________.
The applicant's S.A.T. scores were: _____________________________________________

The applicant's A.C.T. scores were: _____________________________________________

Name person providing this information: ___________________________________

Title:____________________________ Phone #: (____) ____________________________

Address:____________________________________________________________________
******************************************************************************

ATTACHMENT B - COLLEGE TRANSCRIPT SUPPLEMENT
The following is to be completed by the College Registrar if the information is not listed on your college transcripts:

This is to certify that the applicant, ____________________________ is currently
enrolled in __________________________________________________________College,

(Name of College)

located at _____________________________________________________________________.

(Address of College) (City) (State)

The applicant is/will be working toward a/an _______________________________________

(Type of Degree)

degree in the study of ___________________________________________________________.

(Major)

The applicant's cumulative graded point average is ________________________.
Printed name of the College Registrar: ___________________________________________

Signature of the College Registrar: ______________________________________________

Address of the Registrar's Office: ________________________________________________

Phone number of the Registrar's Office: (_____)____________________________________

Page 6

THE LARRY A. HART MEMORIAL SCHOLARSHIP
RECOMMENDATION FORM
To honor the memory of Wildlife Officer/Field Supervisor Larry A. Hart, the Ohio Wildlife Officers' Fraternal Order of Police, Lodge #143, and the Twin Valley Rod & Gun Club have established the Larry A. Hart Memorial Scholarship. Officer Hart's thirty-year legacy of integrity and commitment to the profession of Wildlife Management and Law Enforcement set a timeless standard for all future officers.
NAME OF APPLICANT: _________________________________________________

Your knowledge of this applicant will assist the Scholarship Committee in considering the applicant's qualification(s) for scholarship aid. Please add additional sheets if necessary. We would appreciate your honest recommendation based upon any records and/or personal knowledge pertaining to the following points:
1. Is the applicant the type of person you would recommend for this scholarship?

[ ] No [ ] Yes, Why: ________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

2. Personal Qualifications - What do you consider to be the applicant's outstanding traits

which qualify him/her for this scholarship? (i.e.: character, diligence, emotional maturity,

leadership ability, honesty, etc.): ________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

3. What is your knowledge of the applicant's financial need(s)?_________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

4. Is the applicant the type of person that you would want to respond to assist you in the

time of an emergency? [ ] No [ ] Yes Explain:__________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

5. Are you a family member of/or related to the applicant? [ ] Yes [ ] No
6. Do you have any additional remarks or information that you would like to share about

the applicant?________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
Printed Name: _________________________________________________________________

Signature: _______________________________________________Date: _____/_____/_____

Address: ______________________________________________________________________

Title/Occupation/Relationship:____________________________________________________

Mail this document directly to the Larry A. Hart Scholarship Committee at 174 Briarwood Drive, Mount Vernon, Ohio 43050 before the 15^th day of March.

THE LARRY A. HART MEMORIAL SCHOLARSHIP
RECOMMENDATION FORM
To honor the memory of Wildlife Officer/Field Supervisor Larry A. Hart, the Ohio Wildlife Officers' Fraternal Order of Police, Lodge #143, and the Twin Valley Rod & Gun Club have established the Larry A. Hart Memorial Scholarship. Officer Hart's thirty-year legacy of integrity and commitment to the profession of Wildlife Management and Law Enforcement set a timeless standard for all future officers.
NAME OF APPLICANT: _________________________________________________

Your knowledge of this applicant will assist the Scholarship Committee in considering the applicant's qualification(s) for scholarship aid. Please add additional sheets if necessary. We would appreciate your honest recommendation based upon any records and/or personal knowledge pertaining to the following points:
1. Is the applicant the type of person you would recommend for this scholarship?

[ ] No [ ] Yes, Why: ________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

2. Personal Qualifications - What do you consider to be the applicant's outstanding traits

which qualify him/her for this scholarship? (i.e.: character, diligence, emotional maturity,

leadership ability, honesty, etc.):________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

3. What is your knowledge of the applicant's financial need(s)?_________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

4. Is the applicant the type of person that you would want to respond to assist you in the

time of an emergency? [ ] No [ ] Yes Explain:__________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

5. Are you a family member of/or related to the applicant? [ ] Yes [ ] No
6. Do you have any additional remarks or information that you would like to share about

the applicant?________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
Printed Name: _________________________________________________________________

Signature: _______________________________________________Date: _____/_____/_____

Address: ______________________________________________________________________

Title/Occupation/Relationship:____________________________________________________

Mail this document directly to the Larry A. Hart Scholarship Committee at 174 Briarwood Drive, Mount Vernon, Ohio 43050 before the 15^th day of March.