Form - Pickett & Hatcher Educational Fund, Inc.

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Student Borrower Information

(1) First Name

Middle (No initials)

Last Name

Suffix

(2) Permanent Home Address

(3) City

(4) State

(5) Zip Code

(6) Home Phone

(7) Social Security Number

(8) Date of Birth MM/DD/YY

(9) United States Citizen

(10) E-mail Address

(11) Driver's License Number

(12) Name of College or University

(13) Classification During Loan Period

(14) College City

(15) College State

(16) Borrower's College Phone

(17) Proposed Major

(18) Proposed Occupation

(19) Estimated College Graduation Date

(20) Borrower's High Schools and Colleges/Universities attended, including present

School/College/University

Location: City

Location: State

From: MM/DD/YY

To: MM/DD/YY

(21) Actual or Anticipated Graduation Date

(22) Loan Amount Requested (Up to $15,000 for an academic year)

(23) Actual Beginning Date of Loan Period (Academic Year)

(24) Actual Ending Date of Loan Period (Academic Year)

Endorser Information

(25) First Name

Middle (No initials)

Last Name

Suffix

(26) Mailing Address Same as Applicant

(27) City

(28) State

(29) Zip Code

(30) Permanent Address (Enter if different than 26 (PO Box not acceptable)

(31) Home Phone Number

(32) Business/Work Phone Number

(33) E-mail Address

(34) Social Security Number

(35) Date of Birth

(36) United States Citizen

(37) Relationship to Borrower

(38) Driver's License

Student's cost of attendance for the period of enrollment covered by the loan

Estimated financial assistance for the period of enrollment covered by the loan