MEMORIAL SCHOLARSHIP PROGRAM
ENTRY FORM
DUE APRIL 30, 2009
Student's Name ____________________________________________[_] Male [ ] Female_______
Address __________________________________________________
City, State, Zip _____________________________________________
Phone ____________________________________________________
High School _______________________________________________
Address __________________________________________________
City, State, Zip _____________________________________________
Phone ____________________________________________________
School you plan to attend _____________________________________________
| Name of Parent _____________________________________________ | [ ] Father [ ] Mother [ ] Stepfather [ ] Stepmother |
| Parent's Local # _____________________________________________ | |
| Employed by _______________________________________________ | |
Please enter my name in the 2009 Marshall M. Hicks Memorial Scholarship Program. I understand that the program is open to students who will complete high school and enroll and attend a university, college, or trade school, etc., in 2009 and who are the son or daughter of an active or retired member of the MSUWC, or the son or daughter of an active member who died as a direct result of an on the job injury. I further understand that the awards will be determined by a blind drawing and I am in no way guaranteed to be one of the award recipients.
________________________________________________________________
| Signature of Applicant | Member of MSUWC |
Return completed form to:
MSUWC, 110 W Lenawee, Lansing MI, 48933 or
Fax to: 517-372-9137 or Email to: msuwc@sbcglobal.net
Due date: April 30, 2009
for the Microsoft Word version of this application
for scholarship rules, or
to download the Microsoft Word version
for information on past scholarship rules and winners