RICHARD BRONSON

SCHOLARSHIP
TO THE APPLICANT: (has to be a 2018 High School Senior)

Please complete this application so we can determine your eligibility for receiving funds set aside to
help students who plan to go to post-secondary education, and who satisfy other criteria developed
by the North Dakota Grocers Association.

Complete the sections of this application and forward to:

NDGA, Bronson Scholarship, 200 East Main Avenue, Suite 101, Bismarck, ND 58501

You are responsible for seeing that this application is complete when submitted. NDGA and its
affiliate programs reserve the right to process only applications found to be complete as of the
application postmark deadline of March 9, 2018.

Remember:

-You must be presently employed in the supermarket/grocery industry of a NDGA member and
have been so for at least one (1) year; OR

One or both of your parents or legal guardians must be presently employed in the
supermarket/grocery industry of a NDGA member and have been so for at least two (2) years.

Certification and Permission to use Recipient Information to Announce Scholarship Winners

In submitting this application, I certify that the information provided is complete and accurate to the best of
my knowledge. Falsification of information may result in termination of any scholarship granted.

I agree that if I am offered and accept an award from the North Dakota Grocers Association, the Association
may use my name, the name of my community, the name and address of my school, the amount of the
award, and the name of the post-secondary institution I will attend (my Recipient Information) in press
releases, public announcements, and other fundraising or promotional materials in all media (including the
Internet).

Applicants Signature Date

Parent Signature (if student is less than 18 years old)

Signature of NDGA Member Owner or Manager

Please Post Remove on March 9

The North Dakota Grocers Association

Proudly Announces
2018 Richard Bronson Scholarships
The North Dakota Grocers Association will award several scholarships for the
academic year beginning this fall. Each $1,000 scholarship will be awarded to
the children of full-time employees as well as part-time employees who are full-
time students.

WHO IS ELIGIBLE?
2018 High School seniors who are:
1. Sons and daughters of full-time employees of firms which are members of the
North Dakota Grocers Association. The parent employee must have been
employed for at least two years as of March 9th of the year in which the
scholarships are awarded.

2. Part-time employees who are full-time students and are employed by firms
which are members of the North Dakota Grocers Association. Applicants
must have worked an average of 10 hours per week for at least 12 months as
of March 9th of the year in which the scholarships are awarded.

NOTE: The applicants or the parents of applicants must still be employed by a

dues-paying NDGA member firm at the time the winners are announced.

SELECTION OF WINNERS
Scholarship winners will be selected in April. Winners must enroll in
college as full-time students in the fall.

To obtain a scholarship application,

see your employer or
NDGA,
200 East Main Avenue, Suite 101 Bismarck, ND 58501
Website: www.ndgrocers.com
701-223-4106 Toll-Free 1-888-616-8397 Fax: 701-223-6783
 ID# AWARD AMOUNT

PLEASE PRINT OR TYPE

APPLICANT DATA

Mr.
Ms. Name (Last) (First) (MI) Social Security Number

Permanent Address (Street) (City) (State) (Zip)

() -
Date of Birth (month/day/year) Telephone Number E-Mail Address

Name of
parent/guardian

Permanent mailing address of parent/

guardian if different from applicant
(Street) (City) (State) (Zip)

( ) -
Telephone Number

__________________________________________________

SCHOOL DATA

High School Attended Graduation Date: Month Year

Address ( ) -
(Street) (City) (State) (Zip) Telephone Number

Name of High School

Principal

Name of postsecondary school for

which applicants scholarship is requested:
4-year College/University Vo-Tech
Community College Other

Accredited? Yes No

Address
(City) (State) (Zip)

Enrolling: less than half-time half-time or more full-time

Page 1 of 2
 PERSONAL DATA may use extra paper if needed ID#

Please list the jobs you have had at a supermarket or other employment during the
past 4 years. Indicate dates of employment in each job and approximate number of
hours worked each week.

Date From Date To

Place of Employment Hrs/Wk Manager Mgrs Phone #
(mo/yr) (mo/yr)

List all community (not school) activities in which you have participated without pay during the past 4
years (e.g., Red Cross, church work, volunteer work). Indicate all special awards and honors.
Years Special Awards Total Hrs Organization Leader/
Activity Organization
Partic. Honors, Offices Held Served Sponsor & Phone #

Parents or legal guardian currently employed in the supermarket/grocery industry.

Place of Employment Date From (mo/yr) Manager Mgrs Phone #

TRANSCRIPT INFORMATION

High school seniors must have the following section completed by the appropriate school official.

Cumulative grade point average: /4.0 scale ACT Standard Composite:

( ) -
School Officials Signature Date Title Telephone Number

School Address (Street) (City) (State) (Zip)

APPLICATION CHECKLIST

This application for student aid becomes complete only when you have returned the following materials.
Application
All required signatures
Letters of recommendations not required
Application Deadline: March 9, 2018

Return Application To: North Dakota Grocers Association Attn: Bronson Scholarship
200 East Main Avenue, Suite 101 Bismarck, ND 58501