“An Investment in our Communities”

Gate City BankCommunity Scholarship

Program

Name _____________________________________________________________________________________________________

Address __________________________________________________________________________________________________

City _________________________________________ County _________________ State _______ Zip Code ___________

Telephone _______________________________________________________________________________________________

Parent(s) or Guardian(s) _________________________________________________________________________________

Parent(s) or Guardian(s) address if different than student _______________________________________________

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Name of High School _____________________________________________________________________________________

Class Rank _____________ out of ______________ Cumulative GPA ___________________________________________

College you plan to attend ______________________________________________________________________________

School Activities (include leadership roles or offices held and/or years of involvement):

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Gate City Bank, with 34 offices in 19 North Dakota and Minnesota communities, has been providing financial services for more than 90 years. As a community bank, Gate City Bank is committed to meeting various needs in each of our communities including educational needs

The Gate City Bank Community Scholarship Program will award forty-seven $1,200 scholarships to graduating high school seniors from North Dakota and Minnesota.

Qualifications:• Each applicant must be a high school

senior in North Dakota or within 100 miles of a Gate City Bank location in Minnesota, and plan on attending college in the fall following their high school graduation.

• The applicant must attend an accredited North Dakota, Minnesota, South Dakota, or Montana institution of higher learning (Technical, 2 or 4 year school).

• Gate City Bank employees and dependents of employees are not eligible for this scholarship.

Selection:Criteria taken into consideration will include, scholastic excellence, extra-curricular activities, community involvement, and financial need.

Instructions:• Please complete the appropriate

photo release form at the end of the application prior to submission.

• Save this scholarship application to your computer.

• When complete, submit the release and application to your school counselor before the application deadline.

Application Deadline: April 1, 2015.

ApplicAtion instructions And criteriA for selection

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State how you have contributed your time and talents For a Better Way of Life® for yourself and your community. List any awards, recognitions and activities, leadership positions, number of years of participation, and number of hours spent.

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Describe how Gate City Bank could affect your financial situation with a scholarship that would support you and your family For a Better Way of Life®.

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34 offices to serve you. • gatecitybank.com

Submit an essay of no more than 500 words on your educational and occupational goals that will offer you professional satisfaction For a Better Way of Life® in your future. Include what you have done or will do to help support the success of these goals.

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Important Items:

• Should you be selected as a scholarship winner, you will need to furnish a senior photograph for use in advertising and news releases.

• Should you be selected as a scholarship recipient, Gate City Bank will verify receipt of appropriate photo release form to use your name and photograph in advertisements and in news release announcements.

• Scholarship funds are non-transferable to institutions outside of ND, SD, MN, and MT.

• If the total dollars you receive from all scholarships exceed the cost of tuition and books, the excess may be considered taxable income by the IRS.

Member FDICM-37a (R 1/15)

*The student must fill out this form if they are 18 years of age or older.

PHOTOGRAPHY/INFORMATION RELEASE FORM

I, _____________________________, agree to allow pictures, likenesses and/or information about me to be used for publication, telecast, advertising and/or publicity purposes by Gate City Bank, with its principal place of business at 500 2nd Ave. North, Fargo, N.D., 58102 and Gate City Bank’s assigns, licensees and representatives (collectively “Gate City”).

The rights granted to Gate City under this Agreement shall include, without limitation, the right to publish, print, distribute, telecast, cablecast, or otherwise exhibit my pictures, likenesses and/or information by print, television, radio, digital transmission, multiple distribution system, the internet and by any other means of transmission and reception of information or images whether now known or hereafter developed. The rights to use my pictures, likenesses and/or information also includes, without limitation, the right to use such pictures, likenesses and/or information in news releases, brochures, reports, catalogs, advertisements, publications, on-line computer presentations, and other promotional items, or in any audio, visual or audio-visual format, including, but not limited to, print, still photographs, film, audio, audiotapes, videocassettes, laser discs or CDs.

The rights granted to Gate City under this Agreement shall also include the right to display or communicate my pictures or likenesses in singular or composite form, and to change or alter all such pictures, likenesses or images. I hereby I release Gate City, its subsidiaries and related organizations, and their employees from any liability or responsibility for any distortion, blurring, alteration, optical illusion, changes or use of my pictures or likenesses in composite or other form, whether intentional or not.

I understand that the rights granted under this Agreement are irrevocable and that I retain no right to inspect or approve the finished product or products, the advertising copy, prints or other methods by which my pictures, images and likenesses may be communicated or presented.

In addition, I understand that these pictures, likenesses and/or information may be used by the news media (wire services, newspapers, magazines, radio, television, and on-line computer news services) for distribution on a local, national, or international basis. I also understand that Gate City does not control the use of such pictures or information by news media organizations.

To the extent Gate City displays or communicates my picture, likeness or information, or places my picture, likeness or information on the internet, I understand that the pictures, likenesses and information will be accessible to anyone in the world with a television or internet access and that it may be accessed, reproduced ordownloaded by anyone with access to a television or the internet. I understand that Gate City cannot control or prevent the use, misuse, appropriation or misappropriation of this information by viewers, users of the internet, or others. The pictures, likenesses and information may also be videotaped off the broadcast, or downloaded or printed from the internet, by persons and be seen, used, or transferred by means other than the broadcast or internet. I release Gate City, its subsidiaries and related organizations, and their employees from any liability or responsibility for any use, misuse, reproduction, appropriation, downloading, or any other handling of my pictures, likenesses or information by persons or entities who access the pictures, likenesses or information by television or on the internet or who obtain the pictures, likenesses or information from any source whatsoever.

I understand that Gate City will own all rights, including the copyright, in the pictures, likenesses and accompanying materials. I waive all rights that I may have to any claims for payment of royalties or other compensation in connection with the use of my pictures, likenesses or information. Lastly, I represent that I am authorized to sign this Photography/Information Release Form.

Name_____________________________ Signature_________________________________

Address __________________________ Date_____________________________________

*A parent or legal guardian must fill out this form if the student is under the age of 18.

PHOTOGRAPHY/INFORMATION RELEASE FORM/Child

I, _____________________________, agree to allow pictures, likenesses and/or information about __________________________ (“Child”) to be used for publication, telecast, advertising and/or publicity purposes by Gate City Bank, with its principal place of business at 500 2nd Ave. North, Fargo, N.D., 58102 and Gate City Bank’s assigns, licensees and representatives (collectively “Gate City”).

The rights granted to Gate City under this Agreement shall include, without limitation, the right to publish, print, distribute, telecast, cablecast, or otherwise exhibit Child’s pictures, likenesses and/or information by print, television, radio, digital transmission, multiple distribution system, the internet and by any other means of transmission and reception of information or images whether now known or hereafter developed. The rights to use Child’s pictures, likenesses and/or information also includes, without limitation, the right to use such pictures, likenesses and/or information in news releases, brochures, reports, catalogs, advertisements, publications, on-line computer presentations, and other promotional items, or in any audio, visual or audio-visual format, including, but not limited to, print, still photographs, film, audio, audiotapes, videocassettes, laser discs or CDs.

The rights granted to Gate City under this Agreement shall also include the right to display or communicate Child’s pictures or likenesses in singular or composite form, and to change or alter all such pictures, likenesses or images. I hereby I release Gate City, its subsidiaries and related organizations, and their employees from any liability or responsibility for any distortion, blurring, alteration, optical illusion, changes or use of Child’s pictures or likenesses in composite or other form, whether intentional or not.

I understand that the rights granted under this Agreement are irrevocable and that neither Child nor I retain the right to inspect or approve the finished product or products, the advertising copy, prints or other methods by which Child’s pictures, images and likenesses may be communicated or presented.

In addition, I understand that these pictures, likenesses and/or information may be used by the news media (wire services, newspapers, magazines, radio, television, and on-line computer news services) for distribution on a local, national, or international basis. I also understand that Gate City does not control the use of such pictures or information by news media organizations.

To the extent Gate City displays or communicates Child’s picture, likeness or information, or places Child’s picture, likeness or information on the internet, I understand that the pictures, likenesses and information will be accessible to anyone in the world with a television or internet access and that it may be accessed, reproduced or downloaded by anyone with access to a television or the internet. I understand that Gate City cannot control or prevent the use, misuse, appropriation or misappropriation of this information by viewers, users of the internet, or others. The pictures, likenesses and information may also be videotaped off the broadcast, or downloaded or printed from the internet, by persons and be seen, used, or transferred by means other than the broadcast or internet. I release Gate City, its subsidiaries and related organizations, and their employees from any liability or responsibility for any use, misuse, reproduction, appropriation, downloading, or any other handling of Child’s pictures, likenesses or information by persons or entities who access the pictures, likenesses or information by television or on the internet or who obtain the pictures, likenesses or information from any source whatsoever.

I understand that Gate City will own all rights, including the copyright, in the pictures, likenesses and accompanying materials. I waive all rights that either Child or I may have to any claims for payment of royalties or other compensation in connection with the use of my pictures, likenesses or information. Lastly, I represent that I am authorized to sign this Photography/Information Release Form.

Name_____________________________ Signature_________________________________

Address __________________________ Date_____________________________________

Child’s Name ______________________ Relationship to Child _______________________