8/7/2019 District 19 2011-2012 Scholarship Application Form

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Important! All Applications and required documentation must be submitted as early as possible and postmarked

later than May 16, 2011. Please print clearly and complete BOTH pages of this form. It is the responsibility of all applicants to ensur

that their application, essay, and TRANSCRIPTS are received by the Delegates’ Office. This form should be signed and submitted by malong with the other documents for consideration.

You MUST be a resident of Maryland Legislative District 19 and have attended a Maryland high school to qualifyfor this House of Delegates Scholarship. Please write the name of the school you will be attending below. If you are attendingan out-of-state school due to a unique major , consult the MHEC website (www.mhec.state.md.us.) for approval. To verify your legislative district, visit http://mlis.state.md.us. Select the “Find a legislator” link and complete the lookup form or call 240-777-VOTE.

Name of the school you will attend in the Fall of 2011:

 Is it out of State: Yes No

Degree you are seeking:

Date You Accepted: (mm/yyyy)Full Time Student or Part Time Student (less than 12 credits)

Undergraduate Major:Unique Major? Yes No If yes, please describe below:

Comments:

Personal Essay: Write and submit an essay on one of the following. Limit is 500 words, double spaced:1. Profile yourself 10 years from now. Who will you be and what will you be doing? 2. What going to college means to me and why  List any Academic honors and other Awards:

List recent Work Experiences:

List any additional school, extracurricular, home, work, or community activities below or on a separate page:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please complete BOTH pages of this application and mail as soon as possibleFinal Deadline: May 16, 2011

StudentName: 

First Middle Last

HomeAddress:

Street/ Apt. No.

City State Zip

Current Address (if not same as Home)

Street/ Apt. No.

City State Zip

Phone number:(circle preferred) Daytime: Cell: Evening:

Social Security or ITIN No. SS # or ITIN #

Date/Place of Birth: Date: Place of Birth:

Email Address: Marital Status Single Married

Do you live withyour parents? Yes No

If yes, how many children are dependent on your parents?_________________ 

2011-2012 Maryland House of Delegates Scholarship ApplicationDelegates Arora, Cullison and Kramer: District 19 Montgomery County 

8/7/2019 District 19 2011-2012 Scholarship Application Form

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 Next September, I will be a: Freshman Sophomore Junior Senior or Graduate Student

My Student Status will be: Full time (at least 12 credit semester hours) Part time (6 to 11 semester hours)

I will be graduatingfrom high schoolon: ______________ 

(Date)

Your High School Name and Address: Your highest SAT scores__________ Verbal Date: ____________________ Math Date: ____________________ Written Date: __________

TRANSCRIPTSProvide your most recent high school or college transcript. Applications will NOT be processed without transcripts.

Transcripts attached Transcripts will be mailed by school

IMPORTANT---You must establish your FINANCIAL NEEDS by filling out the following information. ……………………

Your 2010 Personal income: Your 2011 Personal income (estimated):

Place of your Current Employment: (name, address, phone)

 Did you receive any financial aid last year? Yes No If yes, provide name of the sources of any loan, grant, or scholarships you received:

List ALL other 2011-12 applications for financial aid you have applied for and any awards received to date:

State/MHEC? ___________________________________________Other?________________________________________________Please check information about this and other scholarships available as MD state Aid at www.mhec.state.md.us  

Gross Family Income:(This amount is your parents total income)

$0- 20,999 $21,000- 40,999

$41,000- 60,999 $61,000- 80,999

$81,000- 100,999 $101,000 or more

PLEASE NOTE:Delegate scholarships are awarded based onstudent need. Therefore we may request that you provide additional information regarding your personal or your family income.

FAFSA: If you are eligible to apply for Federal Financial Aid, have you submitted a FAFSA? Yes_____ Date submitted:_____Please provide a copy of your Student Aid Report (SAR) ASAP to complete processing your application.

SAR attached For all information about Federal Student Aid, go to www.fafsa.ed.gov 

Mail Signed Application and Documentation to:

Merry Eisner, Aide to Delegate Sam Arora, 6 Bladen, Room 224, Annapolis MD 21401-1991 as soon as possible.

Important Deadline: To be considered, ALL documentation must be postmarked NO LATER THAN May 16, 2011.

To the best of my knowledge, the information reported here is complete and correct.

_______________________________ _________ ________________________________ _________ Student’s signature Date Parent’s signature (if dependent) Date

Also Please Print Names below:

_______________________________________ ________________________________________ 

Please complete BOTH pages of this application form and mail as soon as possibleFinal Deadline: May 16, 2011