The Community Foundation for Greater New Haven

Universal Scholarship Remittmance Form

Please submit this form by June 5, 2015

Question Title

* 1. Name of Scholarship Fund

Question Title

* 2. Grant Number (You can find this number on the report next to the fund name)

Please complete the following for each scholarship recipient.
SCROLL to Question 10 to complete the form after your students have been entered.
(If you have more than 7 scholarship recipients, email Deb Wright at dwright@cfgnh.org
with the additional student information)

Question Title

* 3. Student No. 1

Student's First Name

Student's Last Name

Home Address

Home Telephone Number

College or University

Award Amount

Question Title

* 4. Student No. 2

Student's First Name

Student's Last Name

Home Address

Home Telephone Number

College or University

Award Amount

Question Title

* 5. Student No. 3

Student's First Name

Student's Last Name

Home Address

Home Telephone Number

College or University

Award Amount

Question Title

* 6. Student No. 4

Student's First Name

Student's Last Name

Home Address

Home Telephone Number

College or University

Award Amount

Question Title

* 7. Student No. 5

Student's First Name

Student's Last Name

Home Address

Home Telephone Number

College or University

Award Amount

Question Title

* 8. Student No. 6

Student's First Name

Student's Last Name

Home Address

Home Telephone Number

College or University

Award Amount

Question Title

* 9. Student No. 7

Student's First Name

Student's Last Name

Home Address

Home Telephone Number

College or University

Award Amount

Question Title

* 10. Please describe your selection process for scholarship recipient(s). This question needs to be completed please do not answer (same as last year).

Question Title

* 11. In the space below, please list your committee members with titles. This question needs to be completed please do not answer (same as last year).

Question Title

* 12. Person completing this form:

Name:

Organization:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number: