Bloomingdale Civic Association

2015 SCHOLARSHIP AWARD

Application Cover Sheet
Please provide the following information to supplement your application.

Application date: ____________________________

Applicant name: _______________________________________________________________________

Applicant address: _____________________________________________________________________

Phone number: ________________________________________________________________________

Email address: _________________________________________________________________________

Parent/guardian name: _________________________________________________________________

Name of high school: ____________________________________________________________________

High School graduation date: ____________________________

Name of college, university, or vocational-technical program:

_____________________________________________________________________________________

Address: _____________________________________________________________________________

Hours of community service performed: ____________________________

Type of community service performed:

______________________________________________________________________________________

Contact name for community service performed: _____________________________________________

Phone number: ________________________________________________________________________

Email address: _________________________________________________________________________