United Supreme Council Benevolent Fund

United Supreme Council Ancient and Accepted

Scottish Rite of Freemasonry
Prince Hall Affiliation, Northern
Jurisdiction, U.S.A., Inc.

State Grand Assembly

Name:
Last EDUCATIONAL GRANT
First - DATA REPORT
Middle

Address:
Street City State Zip Code

Telephone: Date of Birth:

Name Parent/Guardian of

Parent/Guardian is / is not a member of Assembly #

High School: City/State/Zip

Date You Will Graduate:

School Activities:

Community Actitities:

List Awards or Special Recognition You Have Received:

What College Do You Plan to Attend

Have You Been Accepted?

If This is a Two Year College, at Which Four Year

College/University Do You Plan to Complete Your Education?

Signature: Date:

Deputy's Signature: Date: