NAME: ______________________________________________________________________

ADDRESS: ________________________________________________________________

TELEPHONE: __________________________________________

DATE OF BIRTH: _____________________ SOCIAL SECURITY ___________________________

Complete the following questions:

1. Name of institution you will attend, or in which you are currently enrolled:

________________________________________________________________________________

2. Course of study you plan to pursue:

________________________________________________________________________________

3. Will you be attending full-time? ( )Yes ( )No

If part-time, how many credits? ________________________________________________

Please feel free to include any additional information which you feel will aid the committee in making a selection.

I CERTIFY THAT , TO THE BEST OF MY KNOWLEDGE, ALL STAEMENTS IN THIS APPLICATION ARE CORRECT. I AGREE TO A PERSONAL INTERVIEW IF REQUESTED BY THE SCHOLARSHIP COMMITTEE AND AT SUCH TIME WILL PROVIDE MY VERIFICATION REQUESTED. MY SIGNATURE BELOW AUTHORIZES THE ABOVE NAMED INSTITUTION TO RELEASE ENROLLMENT INFORMATION TO THE MARTIN D. ANDREWS SCHOLARSHIP COMMITTEE OR AN AGENT THEREOF.

Applicant's signature: _____________________________________________________

Date: __________________________________________