If you have received a scholarship, please complete this form in order that your check will be issued. You can download and print the form by clicking here.

Simpson County Historical Society Scholarship Questionnaire

Full Name: _________________________________________________________

Address: ___________________________________________________________

City, State, Zip: ______________________________________________________

Social Security Number: _______________________________________________

Student Number (if different from social): ________________________________

Name of School: _____________________________________________________

To the Attention of: __________________________________________________

Address of School (where check needs to be mailed): _______________________________

City, State, Zip: ______________________________________________________

Any additional information needed to send your check:

Date __________________-

Please Return to the Simpson County Historical Society in order that your scholarship check will be issued to the university or college.  You may mail, email, or hand deliver.