Alison Mae Regan  Memorial Fund


Alison Mae Regan Memorial Fund

 *Scholarship Application Form*

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


                   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) 












            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.














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.





                 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).


          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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