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Please fill out the information requested below. After you click submit, you will thanked for taking the 'survey.' This is your confirmation that your application has been sent.

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* 1. Member's Name: Last, First, Initial

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* 2. Member Work Site & Shift:

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* 3. Member's Phone #:

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* 4. Parent/Guardian's Name: Last, FIrst, Initial

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* 5. Parent/Guardian's Address:

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* 6. Student's Name: Last, First, Initial

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* 7. Student's Date of Birth:

Date

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* 8. Student's Social Security #:

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* 9. Student's Address:

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* 10. Note: This Scholarship Applies only to NEXT Year's Tuition:
Is applicant a dependant of member as defined by the IRS?

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* 11. I am applying for the (semester):

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* 12. I will be a:

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* 13. I plan on attending ______ college/university.

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* 14. College/University Address:

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* 15. College/University Phone #:

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* 16. Name of graduating High School:

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