Alison Mae Regan  Memorial Fund

AMRMF Forms

Alison Mae Regan Memorial Fund

 *Scholarship Application Form*

Fill out form completely, copy & paste or print & scan. Send electronic file to: www.alimaefund@alimaefund.com

PERSONAL INFORMATION

                   First Name                         Middle Initial                                 Last Name

 

 

                                            

                     Address                                 City                              State                 Zip

 

 

 

                        

                     Phone                         Date of Birth (dy/mo/year)

       /        /              

                                                   

            Male     Female      Social Security Number

        

                                    

                     Parent/Guardian Name

 

                     Parent/Guardian Address and Phone Number(s) 

 

 


                        


          EDUCATION:

 

 

 

 

 

 

 

            School(s) attending/attended:

                     Name                         Address(es)                            Advisor                             Years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

          List the colleges and universities to which you have applied and/or have been accepted.

                      Name                                                                     Address

 

 

 

 

 

 

 

 

          Expected date to begin studies:

 

         What activities are you involved with in school?

  

 

 

 

 

 

 

                List awards you have received.

 

 

 

 

 

  

                List your community (civic and political) involvement.

 

 

 

 

 

 

 

 

 

 

 

 

                WORK HISTORY:

                What jobs have you held? List in order of employment with contact's name and phone number.

 

 

 

 

 

 

 

 

 

 

 

 

 
                
FINANCIAL INFORMATION:

Father’s Name

 

 

Father’s Address

Father’s Telephone

Mother’s Name

 

 

Mother’s Address

Mother’s Telephone

Father’s Occupation

 

 

Father’s Annual Salary

Mother’s Occupation

Mother’s Annual Salary

                How many other members of your family are attending college? Please name if applicable.

 

 

  

                 ADDITIONAL INFORMATION

                 How did you hear about the Alison Mae Regan Memorial Fund?

                 Newspaper           Magazine           Book           School Advisor           Family Member           Internet           Other           

          If Internet, please indicate web site address (url).

 

                                                            ESSAY
          
          In 250 words or less, print very clearly, an essay entitled 
“Why I Deserve This Scholarship and How My 
          College Education Will Help Me Make A Positive Impact On My Life, and My Community."
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                                  PRIVACY ACT STATEMENT
Under the authority of Article 5 U. S. C301, Information Act, your name, address, and your telephone number may be requested.  This information is requested for the purpose of keeping the records of all applicants, forwarding names to other available funds and for AMRMF promotional purposes.  Any individual who does not sign this privacy statement will be excluded from possible lists that may be sent to other scholarship funds and other AMRMF activities.

                                                             Signature of Applicant                                                        Date

 

 

 

 *Indication of your signature constitutes agreement with the Privacy Act Statement.

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