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.

First Middle Last

Student
Name:
Home Street/ Apt. No.
Address: City State Zip

Street/ Apt. No.

Current Address (if
not same as Home) City State Zip
Phone number:
(circle preferred) Daytime: Cell: Evening:

Social Security or
ITIN No. SS # or ITIN #

Date/Place of Birth: Date: Place of Birth:

Email Address: Marital Status Single Married

Do you live with If yes, how many children are dependent on your parents?
your parents? Yes No _________________

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:

Degree you are seeking:

Is it out of State: Yes No

Date You Accepted: (mm/yyyy)

Full Time Student or Part Time Student (less than 12 credits)
Undergraduate Major:
Unique Major? Yes No If yes, please describe below:
Comments:

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: Freshman Sophomore Junior Senior or Graduate Student

My Student Status will be: Full time (at least 12 credit semester hours) Part time (6 to 11 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: Your 2011 Personal income (estimated):

Place of your Current Employment: (name, address, phone)

Did you receive any financial aid last year? Yes No If yes, provide name of the sources of any loan, grant, or
scholarships you received:

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: $0- 20,999 $21,000- 40,999 PLEASE NOTE:

(This amount is your Delegate scholarships are awarded based on
parents total income) $41,000- 60,999 $61,000- 80,999 student need. Therefore we may request that you
provide additional information regarding your
$81,000- 100,999 $101,000 or more personal or your family income.

FAFSA: If you are eligible to apply for Federal Financial Aid, have you submitted a FAFSA?Yes_____ Date submitted:________
Please provide a copy of your Student Aid Report (SAR) ASAP to complete processing your application.

SAR attached For all information about Federal Student Aid, go to www.fafsa.ed.gov

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 Date Parent’s signature (if dependent) Date
Also Please Print Names below:

_______________________________________ ________________________________________

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