APPLICATION FORM - Home Bureau - Home Bureau



New York State Federation of Home Bureaus, Inc.

SCHOLARSHIP AWARD FORM

DUE DATE: AUGUST 1ST

Name of scholarship: Cattaraugus County Home Bureau #89 College: Genesee Community College

FIELD OF STUDY: Human Services, Accounting

Recipient: Name

Address

County

Field of Study

Amount of award (specific)

(Do not leave empty, please ask the college for the amount to be awarded to the student before sending to me.)

Alternate Recipient: Name

Address

County

Field of Study

Semester & Date for which Award is effective

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Date of selection meeting _______________________ Please list names, addresses and phone numbers of Home Bureau Selection Committee attending. If you are a SUB, please note that by your name.

1. _________________________________________________________________________________________________________Phone #__________________________________

2. _________________________________________________________________________________________________________Phone #__________________________________

3. _________________________________________________________________________________________________________Phone #__________________________________

4. _________________________________________________________________________________________________________Phone #__________________________________

COLLEGE PERSONNEL: return this form to Scholarship Chairman: Gay Tidd, 10681 Route 16, Delevan, NY 14042

SELECTION COMMITTEE CHAIRMAN: Please return copies of this form to both:

Gay Tidd, State Scholarship Chairman, 396 Southview Drive, Arcade, NY 14009

Donna Fountain, State Assistant Scholarship Chairman, 1 LaPlante Road, West Chazy, NY 12992

If the scholarship is not awarded, please return this form, and write the reason why it was not awarded

Revised 2015 gmt

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