Road to Success Scholarship 2021

Grinnell Mutual Road to Success Scholarship Program

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*Student's name:

*Student’s address:

*Student's city:

*Student's state:

*Student's ZIP:

*Student's phone:

*Student’s email:

*Parent/guardian name 1:

Parent/guardian name 2:

*High school name:

*High school address:

*High school city:

*High school state:

*High school ZIP:

*High school phone:

*Graduation date:

*High school cumulative: GPA

3.0-3.5 3.6-4.0+

What is the date and time for your school's scholarship award ceremony?

*GMRC auto policy #:

*Auto policyholder name:

*Grinnell Mutual agent’s name:

*Agency's name:

*Agency’s address:

*Agency’s city:

*Agency's state:

*Agency's ZIP:

*Agent’s phone:

Agency #:

*Post-secondary school:

*Post-secondary school city:

*Post-secondary school state:

*Current report card or transcript: (PDF / JPG) Please include your first and last name in the filename.

How did you hear about this scholarship?

Agent Online ad Website Other

If other, describe:

I certify I am a high school senior in good academic standing. I am listed as a driver on a Grinnell Mutual, Grinnell Select, or Grinnell Compass auto policy and have no moving violations or accidents on my driving record.