UFCW Local 8D Scholarship Application

Student/Applicant's Name*

Student/Applicant's Date of Birth*

Student/Applicant's Address*

Street Address Address Line 2 City State ZIP Code

Student/Applicant's Phone Number*

School Attending*

Member's Name*

Must be a member of the Union

Relation to Applicant

Parent
Legal Guardian

Company Employed By*

Member's Address

Street Address Address Line 2 City State ZIP Code

If same as Applicant's Address, please skip

Member's Phone Number*

Member's Personal Email Address*

Member's Electronic Signature*

I certify that all the information on this form is true and complete to the best of my knowledge. I agree to give proof that the applicant is actually enrolled in a college program if his/her name is drawn. I realize that if I do not provide such proof, the applicant will not receive the scholarship.