Paul & Jean Studenski Scholarship Application

 Name: ___________________________________ Date of Birth: __________________

 Address: _______________________________________________________________

 Telephone: _______________________Place of Birth: __________________________

 Name of BDCC Committee sponsor: ________________________________________

 Number of Dependents (if any): ____________ Ages? __________________________

 Name of College where you are accepted or enrolled: __________________________

 What Degree program are you in: __________________________________________ 

 How will you finance your education? (Check all that apply):

Yourself: ___________ Parents / Relatives / Friends: _____________

Student Loans: ____________ Grants: _____________ Scholarships: _____________

Other (specify): __________________________________________________________

By signing the below I certify that, to the best of my knowledge, the above information
is true and I give permission for the Brockton Democratic City Committee and
Scholarship Committee to use my name and image for press releases to announce
scholarship award winners.
 

Signature of Applicant: __________________________________ Date: _____________