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The Maine State Society of Washington, DC and The Maine State Society of Washington, DC Foundation |
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| Applicant's Name: _____________________________________________ |
Date and Place of Birth: _____________________________________________ |
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| Mailing: Address: ________________________________ _____________________________________________ _____________________________________________ |
Phone #: _____________________________________________ Student ID #: _____________________________________________ |
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| Name and mailing address of Institution attending: _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ |
Original date of matriculation: _____________________________________________ Current total course hours: _________________________ Resident of Maine? If yes, for how long? _______________ |
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| If Applicant was not born in or has not resided in Maine, explain parent's connection to Maine: ____________________________________________________________________________________________________ |
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| 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 |
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I,________________________________________________ hereby certify that _____________________________ is enrolled full-time in
(Typed Name of Registrar) (Type name of Student) |
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| 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 ____________________________________________ and is a candidate for a 4 or 5 year undergraduate degree. Type Name of Institution | |||||||||
| Applicant's Student ID #: _______________________________________ | |||||||||
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| Mail application not later than April 1st to: |
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| 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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