Page Title

This portion of the application must be completed by member. This information is

confidential and will not be divulged

Name of Member: __________________________________________

Members UBC ID number: ___________________________________

Address: _________________________________________________

City: _____________________ State ______Zip __________

Phone _________________

Signature: _____________________________ Date: ______________

This portion to be completed by applicant

Name of Applicant: _________________________________________

Date of Birth: ______________

Relationship to member: ______________________________________

Mailing Address: ____________________________________________

City: _______________ ____________ State: _____Zip: ___________

Phone ______________

Signature: _____________________________ Date: _______________

Complete You Must Complete the following information if you have never

previously received this scholarship award (attach additional sheets if needed)

1. What are your post high school education objectives?

2. What university, college or technical school are you attending?

3. Full or part time?

4. List community service work you have performed.

5. List any school activities and awards you have received, and any other information that you feel is relevant in your school career.

6. List any scholarship or financial aid you expect to receive or have applied for.

7. Please indicate APPLICANT'S income from Jan 1,2007-Dec 31,2007

Are you a two-income household? Yes ( ) No ( )

*Any applicant found to have submitted false information or not using the money awarded for its intended purpose is permanently disqualified from receiving future awards.

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