2011-2012 Maryland House of Delegates Scholarship Application Delegates Arora, Cullison and Kramer: District 19 Montgomery County

Important! All Applications and required documentation must be submitted as early as possible and postmarked no later than May 16, 2011. Please print clearly and complete BOTH pages of this form. It is the responsibility of all applicants to ensure
that their application, essay, and TRANSCRIPTS are received by the Delegates’ Office. This form should be signed and submitted by mail along with the other documents for consideration. Student Name: Home Address: Current Address (if not same as Home) Phone number:
First Middle Last

Street/ Apt. No. City Street/ Apt. No. City Daytime: SS # Date: Cell: or ITIN # Place of Birth: Marital Status Yes No Single Married State Evening: Zip State Zip

(circle preferred)
Social Security or ITIN No. Date/Place of Birth: Email Address: Do you live with your parents?

If yes, how many children are dependent on your parents? _________________

You MUST be a resident of Maryland Legislative District 19 and have attended a Maryland high school to qualify for this House of Delegates Scholarship. Please write the name of the school you will be attending below. If you are attending
an out-of-state school due to a unique major, consult the MHEC website (www.mhec.state.md.us.) for approval. To verify your legislative district, visit http://mlis.state.md.us. Select the “Find a legislator” link and complete the lookup form or call 240-777-VOTE. Name of the school you will attend in the Fall of 2011:

Is it out of State:



Degree you are seeking:

Date You Accepted: (mm/yyyy) Undergraduate Major: Comments:

Full Time Student Unique Major? Yes

or No

Part Time Student (less than 12 credits) If yes, please describe below:

Personal Essay: Write and submit an essay on one of the following. Limit is 500 words, double spaced:
1. Profile yourself 10 years from now. Who will you be and what will you be doing? 2. What going to college means to me and why

List any Academic honors and other Awards: List recent Work Experiences: List any additional school, extracurricular, home, work, or community activities below or on a separate page:

__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________
Please complete BOTH pages of this application and mail as soon as possible—Final Deadline: May 16, 2011

Next September, I will be a: My Student Status will be:






Graduate Student Part time (6 to 11 semester hours)

Full time (at least 12 credit semester hours)

I will be graduating Your High School Name and Address: Your highest SAT scores from high school __________ Verbal Date: __________ on: ______________ __________ Math Date: __________ (Date) __________ Written Date: __________ TRANSCRIPTS Provide your most recent high school or college transcript. Applications will NOT be processed without transcripts. Transcripts attached Transcripts will be mailed by school

IMPORTANT---You must establish your FINANCIAL NEEDS by filling out the following information. ………………………
Your 2010 Personal income: Place of your Current Employment: (name, address, phone) Your 2011 Personal income (estimated):

Did you receive any financial aid last year? scholarships you received:



If yes, provide name of the sources of any loan, grant, or

List ALL other 2011-12 applications for financial aid you have applied for and any awards received to date: State/MHEC? ___________________________________________Other?_________________________________________________ Please check information about this and other scholarships available as MD state Aid at www.mhec.state.md.us Gross Family Income: (This amount is your parents total income) $0- 20,999 $41,000- 60,999 $81,000- 100,999 $21,000- 40,999 $61,000- 80,999 $101,000 or more PLEASE NOTE: Delegate scholarships are awarded based on student need. Therefore we may request that you provide additional information regarding your personal or your family income.

FAFSA: If you are eligible to apply for Federal Financial Aid, have you submitted a FAFSA?
SAR attached
For all information about Federal Student Aid, go to www.fafsa.ed.gov

Yes_____ Date submitted:________ Please provide a copy of your Student Aid Report (SAR) ASAP to complete processing your application.

Mail Signed Application and Documentation to: Merry Eisner, Aide to Delegate Sam Arora, 6 Bladen, Room 224, Annapolis MD 21401-1991 as soon as possible.
Important Deadline: To be considered, ALL documentation must be postmarked NO LATER THAN May 16, 2011.

To the best of my knowledge, the information reported here is complete and correct. _______________________________ Student’s signature Also Please Print Names below: _________ Date ________________________________ Parent’s signature (if dependent) _________ Date



Please complete BOTH pages of this application form and mail as soon as possible—Final Deadline: May 16, 2011

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