DR. MICHAEL & MARLENE NISSENBLATT SCHOLARSHIP
Sponsored by the East Brunswick Regional Chamber of Commerce Charitable Foundation
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 your have resided in current location
High School Graduation Date

Address

City, State Zip
 
Father’s Name Mother’s Name
Address Address
   
   
Phone # Phone #
 
Name of Institution you are attending Address of Institution
 
Field of Study

In the area below, write a narrative of 250 words or less “Bringing the Human Touch Back to the Bedside”.

Please provide a transcript of your most recent school records including your grade point average, three Letters of Recommendation, and a summary of your current community programs and/or services.
 
Student Employment Record (2 Years)
EMPLOYER YEAR EARNINGS

EXPENSES (one full Academic Year)

This scholarship can be used only to cover the items A and B below. It may not be used for general living expenses such as apartment rent, automobile expenses, etc. Application with incomplete information in this section will not be considered.

A. Tuition and Fees (full academic year, not monthly)
B. Books and Supplies
C. Room and Board
D. Total of above – Add lines A, B & C

ASSETS AND INCOME (annual)

E. Employment
F. Scholarship
G. Aid
H. Grants
I. Family
J. Trusts, etc.
K. Cash
L. Securities
M. Other
N. Total of above – Add lines E thru N

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.