Scholarship Pre-Registration

Member Account Number

Member Name

First

Last

Service Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Member Email

Daytime Phone Number

Relationship to Student

Parent/Guardian

Student

Student Name

First

Last

High School Attended

Graduation Year

Post Secondary College/School to Attend

Student Phone Number

Student Email

Where did you hear about the Farmers RECC Scholarship?

School

Family Member

Kentucky Living Magazine

Other Advertising

Cooperative Employee

Social Media

Other

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