SPRING PAGE 7

APPLICATION FOR LOCAL 1104 SCHOLARSHIP AWARD 2O1O

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SECTION A:
Name of Applicant:
(last) (first) (middle)

Home Address:
(street) (city) (state) (zip)

Date of Birlh: Social Security #:

(month) (day) (yea|

Sex: Home Phone #:

(male or female)

Name of Sponsoring Local 1 104 Member:

(last) (first) (middle)

Home Address:
(street) (city) (state) (zip)

Work Location:
(street)

Your relationship to sponsoring Local 1

'104 Member:

ls the sponsoring member in good standing? Retired: Deceased:

(yes or no) (yes or no) (yes or no)
lf the answer to the second or third oart of the a bove question is yes, indicate the date of retirement or death:
Are you attending, or have you been accepted by an accredited college or university?
You must attach a letter of acceptance or other documentary proof with this application, showing acceptance or attendance
at an accredited colleqe or universitv.
Do you fully intend to obtain a college degree?
(yes or no)
lf the answer is NO, explain:

lf selected for this scholarship award, I fully agree to adhere to the rules and decisions that are made by the Local 1104
Scholarshio Fund Committee.

(signature of applicant) (date)

L
I

SECTION B:
This is to certify: is:
( ) An active member of CWA Local 1 104;
( ) The spouse or child of an active member of CWA Local 1104;
( ) A retired member of CWA Local 1 104;
( ) The spouse, child, or grandchild of a retired or deceased member of CWA Local '1104.

Signature of Local Officer:

Title: Date: