Name:                                                                                

Address:                                                                                                          

Telephone:                                          


Member's Name:                                                                     


Father's Name:                                                                       

Address:                                                                                                          

Job Title and Place of Employment:                                                                              

Mother's Name:                                                            

Address:                                                                                                 

Job Title and place of Employment:                                                                              

Number of Dependent children and ages:                                                       

School you will be attending:                                                                     

Address:                                                                                                  

Annual total cost:                               

Field of study:                                                                                                  

Address:                                                                                                            

Please enclose the following:
1. Photo copy of last report card and school transcript.
2. Two character references written by non-family.
3. 50 to 100 word paragraph about yourself, hobbies, clubs, future ambitions etc.

Application for scholarship must be postmarked by March 1st.
Recipient (s) will be notified in April.

This is a second semester scholarship. The money will be mailed to your school on
confirmation from the school that you are returning, and in good standing.

                  Please mail to: Southern Maine Sno-Goers
                                        P.O. Box 1083
                                        Sanford, Maine 04073
                                        Attention. Scholarship Committee
Justin Harvey Memorial Scholarship
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