MARYJANE CARR SCHOLARSHIP FUND RECIPIENT INFORMATION FORM Administered by FirstMerit PrivateBank 100 E. Michigan Avenue, Suite 200, Jackson, MI 48201 Phone: 517.788.2772 Fax: 517.788.2776 TO BE COMPLETED BY STUDENT RECIPIENT: Name’ “\ny\Re. Peis Pena€ Last First Middle High Schoo!: i wt i noo 1 Home Address: ligWS{_ 20 mile yood. Sheet L us Sty State Zip Home Phone: _J\a4-98lo-BO)2 cell Prone: HLT“ TUS -F 135 Emaii Address: levsS. Woe yO iC PLEASE PRIJT CLEARLY! Social Security Number. ABY- 14-3 703 College You Plan to Attend: _TOCILSON eae ‘Are you or your family an employee of FirstMerit Bank, N.A.? Dyes Bio Bo you havea nancial need fr his scholarship (Annual family ected gros income (AG!) a8 reported ‘on income taxes of $80,000 or less): es TONo Grade Point Average (must be 2.5 or higher to qualify) ATTACH TRANSCRIPT We the undersigned understand that any intentional falsification of any of the statements made in this application may eliminate me ftom any further corisideration. 04 (04/2615, Date Applicant's Signature Parent/Guardian Signature if Applicant under 18 Date TO BE COMPLETED BY HIGH SCHOOL: hereby recommends the above student to recelve @ scholarship Name of High School in the amount of $1,160 from the Maryjane Carr Scholarship Fund, Date Printed name & tile of person signing on behalf of school Phone Number: