cheryl kagan - district 17 annapolis, md 21401 home phone: … · cheryl c. kagan maryland state...

Cheryl C. Kagan Maryland State Senate District 17 (Rockville & Gaithersburg) _____ Education, Health and Environmental Affairs _____ Joint Audit Committee James Senate Office Building 11 Bladen Street, Room 203 Annapolis, MD 21401 301-858-3134, 410-841-3134 800-492-7122 Ext. 3134 [email protected] DISTRICT 17 SENATORIAL SCHOLARSHIP APPLICATION FORM Instructions 1. Submit completed application and accompanying essay to the office of Sen. Cheryl C. Kagan, 203 James Senate Office Building, Annapolis, MD 21401 or email to [email protected]. 2. If this form is incomplete, inaccurate, not signed, or does not include the essay, it will not be considered. 3. Please certify that you are a registered voter in District 17 (if eligible) and that you voted in the 2014 Primary and/or General Election. Your partisan preferences are completely irrelevant to us, but you must have participated in the state electoral process. 4. You must submit a new application each semester. 5. The Cheryl C. Kagan Senatorial Scholarship Committee is a non-partisan review panel that focuses on student need, academic performance, and civic participation/engagement for students who live in Maryland’s District 17th district. Personal Information Student’s Name: Parent/Caregiver Name: Home Address: City: State: Zip: Home Phone: Student Cell Phone: Student ID#: Student E-mail: Academic Information Name of College or University: Credit Hours Earned to Date: Semester for which application is being made — term and year (i.e, Spring 2015): How many credit hours do you plan on taking: GPA: Declared (or Intended) Major: Scholarship Amount Requested: Essay Requirement In a separate PDF, with your name, please submit a 250- to 500-word essay. In it, tell us about yourself, your community involvement, what inspires you, and how this scholarship would help you to further your goals. Please indicate the following: ______ I certify that I am a registered voter in District 17 and participated (if eligible) in the 2014 Primary and/or General Election. ______ I hereby release to the Senatorial Scholarship Committee, access to my voting history file. ______ I hereby release to the Senatorial Scholarship Committee, access to my academic records, as necessary. ______ I am a resident of District 17, but I am not eligible to vote. Signed: Date: Scholarship Committee Use Only Reviewers: Amount Awarded: Date: Remarks:

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Cheryl C. KaganMaryland State Senate

District 17 (Rockville & Gaithersburg)

_____Education, Health and Environmental Affairs

_____Joint Audit Committee

James Senate Office Building11 Bladen Street, Room 203

Annapolis, MD 21401

301-858-3134, 410-841-3134800-492-7122 Ext. 3134

[email protected]

DISTRICT 17 SENATORIAL SCHOLARSHIP APPLICATION FORMInstructions1. Submit completed application and accompanying essay to the office of Sen. Cheryl C. Kagan, 203 James Senate Office Building,

Annapolis, MD 21401 or email to [email protected]. 2. If this form is incomplete, inaccurate, not signed, or does not include the essay, it will not be considered.3. Please certify that you are a registered voter in District 17 (if eligible) and that you voted in the 2014 Primary and/or General Election.

Your partisan preferences are completely irrelevant to us, but you must have participated in the state electoral process. 4. You must submit a new application each semester.5. The Cheryl C. Kagan Senatorial Scholarship Committee is a non-partisan review panel that focuses on student need, academic

performance, and civic participation/engagement for students who live in Maryland’s District 17th district.

Personal InformationStudent’s Name: Parent/Caregiver Name:Home Address:City: State: Zip:Home Phone: Student Cell Phone:Student ID#: Student E-mail:

Academic InformationName of College or University: Credit Hours Earned to Date:Semester for which application is being made — term and year (i.e, Spring 2015):How many credit hours do you plan on taking: GPA:Declared (or Intended) Major: Scholarship Amount Requested:

Essay RequirementIn a separate PDF, with your name, please submit a 250- to 500-word essay. In it, tell us about yourself, your community involvement, what inspires you, and how this scholarship would help you to further your goals.

Please indicate the following: ______ I certify that I am a registered voter in District 17 and participated (if eligible) in the 2014 Primary and/or General Election. ______ I hereby release to the Senatorial Scholarship Committee, access to my voting history file.______ I hereby release to the Senatorial Scholarship Committee, access to my academic records, as necessary.______ I am a resident of District 17, but I am not eligible to vote.

Signed: Date:

Scholarship Committee Use Only Reviewers:Amount Awarded: Date:Remarks:

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