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The Maine State Society of Washington, DC Foundation
 
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SCHOLARSHIP APPLICATION
 
Applicant's Name:

Date and Place of Birth:

Mailing Address:

Name and address of institution attending:
Phone #: _______________________________________
Student ID #: ____________________________________
Email address ___________________________________		 Current total course hours: ______________________
Resident of Maine? If Yes, for how long? _____________
Original date of Matriculation: __________________
If Applicant was not born in or has not resided in Maine, explain parent’s connection to Maine:
_______________________________________________________________________________________________
   
Indicate by (X) that the following are attached:
Composition (  ) Work Sample (  ) Transcript (  ) Registrar’s Certificate (  )

APPLICANT'S CERTIFICATION OF UNDERSTANDING CONCERNING CURRENT TERM GRADES
I understand that if I am selected to receive a scholarship, I must receive satisfactory grades at the end of the preceding term which will qualify me, according to my institution's standards, to enroll in the next term, full-time, and continue without restrictions (such as academic probation or course load reductions) as a 4 or 5 year undergraduate degree candidate.
Signature : ________________________________________________         Date : _________________________
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THE MAINE STATE SOCIETY OF WASHINGTON, D.C. FOUNDATION INC.
SCHOLARSHIP PROGRAM CERTIFICATION OF THE COLLEGE OR UNIVERSITY REGISTRAR
I,_______________ hereby certify that ___________________________ is enrolled
   (Typed Name of Registrar)                                                                  (Typed Name of Student)
full-time in ________ semester hours, or the equivalent in quarter hours or courses under a course system, or is enrolled full-time in a combined college/university or other postsecondary Institution approved by the college/university program which leads to a 4 or 5 year degree at________________________________________________________________________
                                                                                                                             (Typed Name of Institution)
and is a candidate for a 4 or 5 year undergraduate degree.
Applicant Student ID #: __________________________
______________________________________________ ___________________________ _________________
  Signature of Registrar   Typed Title  Date
 
Mail application not later than April 1st to:
Maine State Society of Washington, DC Foundation Scholarship Program
c/o Joan M. Beach
4718 Columbia Road
Annandale, VA 22003-6110
 
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