Application Form

BLINDED VETERANS ASSOCIATION AUXILIARY

RENEE FELDMAN SCHOLARSHIP

2010 -2011 ACADEMIC YEAR

General Instructions

1.  Please read the instructions and questions on this application carefully before attempting to supply the information requested.

2.   Please type, prepare on word processor, or print plainly in black ink the information requested on this form and in all supporting statements.

3.   Whenever the space provided on the form is inadequate, please attach a separate sheet or sheets (on 81/2" x 11" paper) to present fully the information requested.

4.  Applicant's name should be clearly printed on each page of this form, on each additional sheet and on all documents submitted.

DATE OF APPLICATION: ___________________

NAME: ________________________________________________________________

                            First                    Middle                 Last             

HOME ADDRESS: _______________________________________________________

Street No.                             City                            State     Zip

DATE OF BIRTH: ____________ SEX;_________

HOME TEL: #____________ SOCIAL SECURITY NO: ____________________

STATE IN WHICH YOU CLAIM RESIDENCE: ___________________________

PROVIDE THE FOLLOWING INFORMATION

ABOUT YOUR BLINDED VETERAN.