MLSA 4928 - Scholarship Application

Address:

Street________________________City__________________Zip___________________

Birthplace______________________________________Birthdate__________________

Mother's Name___________________________ Occupation _______________________

Father's Name ___________________________ Occupation ________________________

Library where parent is employed __________________________________________

Family (AGI) Adjusted Gross Income _________________________________________

Applicant now attending:

School__________________________________City____________________________

Ages of other children at home_______________________________________________

Date of Graduation________________________________________________________

Name of College or University you plan to attend________________________________

Have you been accepted for admission?________________________________________

Expected amount of expenses for freshman year________________

Field of interest: Major______________________Minor__________________________

Have you received and/or do you expect to receive any other scholarship?_____________

From Whom?_____________________________Amount_________________________

I have read all the scholarship rules and instructions in the informational pamphlet and do hereby submit this application for a Scholarship.

Signature________________________________________________________________

Applications must be postmarked by May 1, 2010