DAVID GERMAIN, SR. MEMORIAL SCHOLARSHIP FUND

DAVID GERMAIN, SR. MEMORIAL SCHOLARSHIP FUND
East Brunswick Regional Chamber of Commerce
PO Box 56 – 21 Brunswick Woods Drive
East Brunswick, New Jersey 08816

CONFIDENTIAL SCHOLARSHIP APPLICATION

Name

Date of Birth

Address



E-Mail

Phone #

Fax #

Length of time family has resided in current location

Father’s Name		Mother’s Name
Address		Address


Occupation		Occupation
Phone #		Phone #

Parents Status	Marital Status	Education
Father
Mother

EMPLOYMENT INCOME (annually before taxes)

OTHER INCOME (annually before taxes)

Father's		Interest
Mother's		Dividends
Family total		Securities
		Rental
		Business
		Pensions
		Social Security
		Other
		Total

Number of Dependents Claimed on the most recent tax return

Dependent Name	Age	Relationship	In School	Tuition Amount

TO BE COMPLETED BY ALL APPLICANTS

Student/Applicant

Student Employment Record (2 Years)

ASSETS
Cash
Securities
Other
Total

EMPLOYER	EARNINGS	YEAR

Budget for one full Academic Year of

This scholarship can be used only to cover the items A, B and C below. It may not be used for general living expenses such as rent, automobile expenses, etc. Incomplete or unnecessary information in this section will not be evaluated.

A. Tuition and Fees (full academic year, not monthly)
B. Books and Supplies
C. Room and Board (if not living at home)
D. Total of above – Add lines A, B & C
E. Parent(s) Contribution
F. Student’s Contribution
G. Other Relatives’ Contribution
H. College Work/Study Employment
I. Other Scholarships, Grant or Loans, Pending or Granted (list name & amounts in detail)



J. Total of above – Add lines E, F, G, H, & I
Amount needed to balance school budget for one year Subtract line J from line D.

In the area below, list Honors & Awards (Non-school Civic related)

In the area below, list offices or positions held (Organization, position, year)

In the area below, list other activities (School or Civic)

In the area below, please write a narrative (250 words or less) as to your background and/or special needs that would merit the scholarship award.

INSTITUTIONS BEING CONSIDERED:

Place a check mark next to institutions that have sent you an acceptance letter and a check mark next to
the school you plan to attend.

Institution Name	Accepted	Plan to attend

PLEASE PROVIDE A TRANSCRIPT OF YOUR SCHOOL RECORDS INCLUDING YOUR GRADE POINT AVERAGE, SAT SCORES & 3 LETTERS OF RECOMMENDATION.

By submitting this application, I certify that all information contained in this financial statement is true and accurate. Any information considered misleading or the omission of information that would mislead the committee could cause the applicant to be disqualified.