HOUSE OF DELEGATES SCHOLARSHIP APPLICATION

DELEGATE ERIC M. BROMWELL

 

   ____-____-_______             ___________________________        ___/____/_____        ____________________

Social Security Number                    Student’s Full Name                       Date of Birth                    Email Address

 

______________________________    ___________________     _______    _______         (____)_____-_______

Street Address                                                               City                      State         Zip Code             Phone Number

_________________________ _________      _________________________________       _______________

Father’s Name (if dependent)                                                      Occupation                                            Income

 

________________________________ __         _______________________________        ________________

Mother’s Name (if dependent)                                                         Occupation                                      Income

 

Total Household Income $____________

Currently:

Received Scholarship from Delegate Bromwell for previous school year:   _______

          ______ High School Senior

Most Recent Cumulative GPA: ________

          ______ Undergrad Student

Combined SAT Score:  _______

          ______  Grad Student

 

          ______ Not Currently Enrolled in School:

 

_____________________________       ________________________       _______     ___________________

High School Attended                                                    City                                      State             Year Graduated

 

_______________________________________                   ____________________________________________

College you (will) attend                                                                                                       Address

 

 

Extracurricular Activities & Community Service:

___________________________________________________________________________________________

___________________________________________________________________________________________

 

Career Goals:

___________________________________________________________________________________________

___________________________________________________________________________________________

 

_______________________             ________                      ___________________________________     _______

Student Signature                                    Date                              Parent/Guardian Signature (if dependent)       Date

 

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED. IF NOT APPLICABLE, PUT N/A