Scholarship Program

Lottery No.

PLEASE PRINT CLEARLY

PARENT1 NAME:
  Last Name First MI

PARENT2 NAME:
  Last Name First MI

ADDRESS:
CITY: STATE: ZIP CODE:

DAYTIME PHONE NUMBER:

ALTERNATE PHONE NUMBER:

FAMILY SIZE INCLUDING SELF:

PARENT 1 CURRENTLY EMPLOYED:

YES NO

IF YES, NAME OF EMPLOYER:

EMPLOYER TELEPHONE NUMBER:

PARENT 1 GROSS INCOME: $

CHECK ONE THAT APPLIES:

WEEKLY:

BIWEEKLY:

BI-MONTHLY: MONTHLY: 

PARENT 2 CURRENTLY EMPLOYED:

YES NO

IF YES, NAME OF EMPLOYER:

EMPLOYER TELEPHONE NUMBER:

PARENT 2 GROSS INCOME: $

CHECK ONE THAT APPLIES:

WEEKLY:

BIWEEKLY:

BI-MONTHLY: MONTHLY: 

PARENT 1 OTHER SOURCE INCOME:

AMOUNT: $

PARENT 2 OTHER SOURCE INCOME:

AMOUNT: $

PARENT 1 CURRENTLY IN EDUCATION/TRAINING?

YES NO NUMBER OF HOURS WEEKLY:

IF YES, NAME OF INSTITUTION:

PARENT 2 CURRENTLY IN EDUCATION/TRAINING?

YES NO NUMBER OF HOURS WEEKLY:

IF YES, NAME OF INSTITUTION:

CHILDREN IN HOUSEHOLD:

 
        SEX
Last Name First MI Date of Birth  M F
        SEX
Last Name First MI Date of Birth  M F
        SEX
Last Name First MI Date of Birth  M F