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Scholarship Award Request Form

Scholarship Award Request Form

 

Member Name:              __________________________________________

Member Email address: __________________________________________

Member Mail address:   __________________________________________

                             __________________________________________

Member telephone:       __________________________________________

Member Since:              ________/________________ (MM/YYYY)

Class title:                      __________________________________________

Class location:               __________________________________________

__________________________________________

Class date(s):                __________________________________________

Class tuition:                  $_________________________________________

Award amount requested: (up to $300): $____________________________

I consent to publicity associated with any award related to this request.  

Member Signature: ____________________________Date____/____/____

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