Charles J. Harbin, III

Memorial Scholarship Fund The CJH3 Memorial Scholarship Fund was established in the Fall of 2011

to commemorate the life of Charles J. Harbin, III by providing financial

assistance to help college students with limited financial resources achieve

high academic goals. Charles found his calling in education and this scholarship

will serve as a keynote remembrance of him and his dedication to his students.

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“Life shrinks or expands in

proportion to one’s courage.”

Anais Nin

Charles J. Harbin, III Memorial Scholarship Fund

The Award

The Criteria

Applicants must demonstrate financial need.

Applicants must be a resident of the state of Georgia;

however, award recipients may attend college anywhere in

the United States. While preference is given to applicants

who attended Roswell High School, all qualified applicants

are considered for an award.

The CJH3 Memorial Scholarship is awarded annually in an

amount ranging from $1000 - $1500 for each recipient with

½ of the award given at the beginning of the academic year

and ½ given at the midpoint of the academic year, upon

maintaining GPA requirements and enrollment as a

full-time student. All grants must be applied to tuition and

fees only and will be paid directly to the institution.

Candidates for the scholarship must meet all listed

requirements and submit all requested materials to the

CJH3MSF Selection Committee by the appointed deadline.

Late applicants will not be considered.

High school seniors entering U.S. colleges or universities

are eligible to apply for the scholarship. It is open to any

field of study. Awards may only be used for undergraduate

study and are limited to those seeking a first bachelor’s

degree.

Applicants must have at least a 2.75 GPA on a 4.0 scale, be a senior in high school, and will be entering a college

or university for the first time in Fall 2017.

©2011-2017 CJH3 Memorial Scholarship Fund. All Rights Reserved.

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Applicants must demonstrate a history of pursuing goals and aspirations with integrity,

resolution, self-discipline and sound judgment, and a desire to make a meaningful contribution

to society.

Scholarship Process

Verify you meet all scholarship criteria in this application (find out more online at

www.CharlesHarbin.com). Complete and submit the entire online application by the stated

deadline, which includes:

Complete the Scholarship Application.

“If it could talk, how would the inanimate object(s) integral to your passion describe you? (e.g., your guitar, soccer ball, pen, etc.)”

A 500 word original short story using one of these titles:

~ Another Brick in the Wall ~ The Travel’s Mind ~ Conversation with a Turtle

~ The Green Jeep ~Answer to a Beautiful Poem

A letter of recommendation from an adult who knows you in an academic or professional capacity (ex: educator, coach, employer, supervisor, etc.) You may provide more than one recommendation.

An official copy of your latest academic transcript.

An official copy of your latest FAFSA SAR (Free Application for Federal Student Aid Student Aid Report) Please feel free to black out any personal information like social security numbers.

Please note that if you do not meet all of the requirements above, your application may be

disqualified.

A 500 word essay answering the question:

A copy of the acceptance letter you received into an accredited 2-year or 4-year college or university in the United States for Fall of 2017. If you have not received your acceptance letter yet, you will be required to provide a copy if selected as a scholarship recipient.

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Applicants may, at their option, submit supplemental materials outside of the requested items

to support their application. Any supplemental materials you would like to submit (copies of

certificates, extra recommendation letters, videos, DVD’s, CD’s, original artwork, and other

materials) outside of the requested documentation must also arrive in your complete application

packet. Mark each item clearly with your name, and reasoning for inclusion. Supplemental

materials mailed separately risk being discarded. Please note these items will not be returned.

Mail all application materials together in one packet. We will make exceptions only for academic

transcripts as we understand that some institutions do not allow students to handle these

documents. Please note that academic transcripts, if sent separately from the application, must

still be postmarked by the scholarship deadline. If individuals who are providing

recommendation letters would like to protect the privacy of their recommendation letters, they

may give the applicant their letters in sealed envelopes to be included with other application

materials.

Charles J. Harbin, III Memorial Scholarship

3000 Old Alabama Road Suite 119-352

Alpharetta, GA 30022

CJH3MSF Contact

If you have a personal story or memory about Mr. Harbin, a.k.a. “Harbs”, please take a moment

to share it online at: http://charlesharbin.com/contact-us/

The Scholarship Committee invites you to visit the website for further details about the

scholarship and its namesake. The committee may also be reached via the contact page on

www.CharlesHarbin.com.

All applications and supporting materials submitted to the CJH3MSF Committee must be

received by the application deadline, April 22, 2017. Late applications will not be considered.

Mail your completed application with all supporting materials in one package postmarked by the

deadline of April 22, 2017, to:

©2011-2017 CJH3 Memorial Scholarship Fund. All Rights Reserved.

PERSONAL INFORMATION Name:

Mailing Address:

Number and Street/Apt. #

Phone: Home Cell E-mail address: One regularly accessed – please write clearly Date of Birth:

Citizenship:

U.S.

Other:

Parents’ Marital Status: Married Separated Divorced Mother remarried Father remarried If parents are separated/divorced, check your primary residence:

YOU MUST ENTER NAMES FOR BOTH PARENTS UNLESS UNKNOWN

Father’s Name:

Mother’s Name:

Living?

Father’s Place

of Work:

Occupation:

Mother’s Place of Work:

Occupation:

Siblings – List full names and ages: 1.

4.

2.

5.

3.

6.

Office of Student Accounts or Bursar address of the above (this must be accurate in order to send scholarship checks):

Intended/Declared Major: Will you be a full time student? High School Name: HS Year of Graduation:

CHARLES J. HARBIN, III MEMORIAL SCHOLARSHIP FUND

APPLICATION FORM

Nickname: Last First M.I. Mr./Miss/Mrs./Ms.

City, State, Zip

with mother with father other:

Living?

Guidance Department in High School College Contact Internet Other:

Did you know Mr. Charles Harbin?

Where or from whom did you hear about the Charles J. Harbin, III Memorial Scholarship?

Future Career Interest: Current GPA:

20172018

College/university you will be attending for the school year 2017-2018:

Goal #1:

Goal #2:

Please limit your answers to this sheet, but do not feel it necessary to fill the whole space provided.

B. SHORT STORY - On a separate computer-generated/typewritten sheet(s), complete the following (500 word min):

~ Conversation with a Turtle

~ The Green Jeep

~ Another Brick in the Wall

~ A Traveler's Mind

If it could talk, how would the inanimate object(s) integral to your passion describe you? (e.g., your guitar, soccer ball, pen, etc.)

ESSAY PAGE

In your own handwriting, respond to the question in the spaces below.

C. GOALS - Please list three goals that you have for yourself and explain why they are important to you.

A. ESSAY - On a separate computer-generated/typewritten sheet(s), respond to this question (500 word min):

Goal #3:

Write an original short story using ONE of these titles:

~ Answer to a Beautiful Poem

OPTIONAL: If you have chosen to include any supplemental material to support A, B or C above, please detail it here. (e.g., "Enclosed CD contains my original music and corresponds with ESSAY A," or "Enclosed original artwork illustrates SHORT STORY B," or "Enclosed Achievement Certificate corresponds with GOAL #3.") Supplemental materials are not required.

1.

2.

3.

4.

5.

6.

EMPLOYMENT List jobs (including summer employment) you have held in the past three years with the most recent first. Employer

Position

#Hours/week Summer

#Hours/week School Year

Dates of Employment

ACTIVITIES OUTSIDE THE CLASSROOM

What do you do when you are not in class? For the past three years, what activities (exclude employment here) have you participated in at school, your community, or home? Briefly describe your involvement.

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ADDITIONAL INFO Is there any anything else you would like us to know when we consider your application?

Activity and Description of Involvement Year Year Year Position Held (if applicable)09/1014/15 15/16 16/17

2.

3.

4.

5.

6.

Signature: Date:

CHECKLIST:– check one box for each number

Essay A – on a separate page. Staple multiple pages of the essay, but do not staple the essay to the application.

Short Story B – on a separate page. Staple multiple pages of the short story, but do not staple the short story to the application

Official Transcript – an official copy of your latest academic transcript, with SAT/ACT scores. If you are selelected as a scholarship recipient, you may be asked to submit your Fall grades as well.

Copy of Student Aid Report (SAR from FAFSA) - an official copy of your latest FAFSA SAR (Free application for Federal Student Aid Student Aid Report). Do not submit your application without it. Please feel free to black out any personal information like social security numbers.

Optional – I have chosen to include supplemental materials that will further showcase my talents, abilities and/or aspirations. I understand all supplemental materials must be labeled clearly with my name and reasoning for inclusion, and must arrive in the same package as my application for consideration. I understand that these materials will not be returned to me.

APPLICANT’S SIGNATURE

I certify that all the statements made in this application form are true, complete, and correct to the best of my knowledge and belief, and are made in good faith. I have also read and noted all requirements listed on this application and its cover sheet and understand that an incomplete or late application will disqualify me from consideration for this award.

If awarded a scholarship, I give the Charles J. Harbin, III Memorial Scholarship Fund permission to use my name, any photographs, and writings or submitted materials (with or without attribution) provided to the organization to be used in any of its publication material, reports, press releases, website, and activities associated with its scholarship program. I understand that all financial and academic information from my transcript and application is, and shall remain, confidential.

I give my consent for my school counselors, teachers or director and representatives of the Charles J. Harbin, III Memorial Scholarship Fund to discuss my eligibility and need for scholarship assistance.

Signature: Date:

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1. Application – pages 1-4 stapled together.

Student name::

Parent name::

Letter of Recommendation - a letter of recommendation from an adult who knows you in an academic or professional capacity (ex: educator, coach, employer, supervisor, etc.)

If student is under 18 on April 22, 2017:

7. College Acceptance Letter - a copy of the acceptance letter you received into an accredited 2-year or 4-year college or university in the United States with full-time undergraduate status for Fall of 2017. If you have not received your acceptance letter yet, you will be required to provide a copy if selected as a scholarship recipient.