Testing the form General InformationName* First Last Phone*Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code High School* Father/Stepfather/Guardian Name* Father/Stepfather/Guardian Occupation* Mother/Stepmother/Guardian Name* Mother/Stepmother/Guardian Occupation* College you will be attending* Major* Name DeKalb County Farm Bureau membership is listed under School ActivitiesList Major School Activities*List major school-related activities (office held, awards, competitions, level of participation, and year). One entry per line. Community ActivitiesList all Community Activities*List involvement and achievements in major non-school and community activities. Do not duplicate activities listed above. Student Statement – Part AIn the space provided, explain your educational and career objectives and long-term goals.* Student Statement – Part BIn the space provided, explain why you should be selected to receive a Farm Bureau scholarship.* Student EssayIn the space provided, please answer the following question: How can Farm Bureau engage students, like you, to share positive information about agriculture?* Work ExperienceList your work experience. Please provide the Year, Name of Employer, and Type of Employment.* Certification StatementI hereby certify that the information on this application is true and accurate to the best of my knowledge as evidenced by these signatures. I understand that all information contained on this application is subject to verification and that false information will lead to disqualification. Student Agreement* I agree to the above certification statement. Parent Agreement* I (the parent) agree to the above certification statement. Date* PhoneThis field is for validation purposes and should be left unchanged.