HOUSE OF DELEGATES SCHOLARSHIP APPLICATION
DELEGATE ERIC M. BROMWELL
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Social Security Number Student’s Full Name
Date of Birth
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Street Address City State Zip Code Telephone
Number
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Father’s
Name (if dependent) Occupation Income
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Mother’s
Name (if dependent)
Occupation Income
Total
Household Income: $___________ Currently:
High School Senior: 1
Received Scholarship from
Delegate Bromwell
for Previous School Year:
1 Undergrad Student: 1
Most Recent Cumulative GPA: __________ Grad
Student: 1
Combined SAT Score: __________ Currently
Not Enrolled in School: 1
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High
School Attended City State Year Graduated
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College you (will) attend Address
Extracurricular Activities & Community Service:
______________________________________________________________________________
______________________________________________________________________________
Career Goals:
______________________________________________________________________________
______________________________________________________________________________
____________________________________ ______________________________________
Student
Signature Date Parent/Guardian Signature (if
dependent) Date