Corbin Educational Scholarship

APPLICATION FOR SCHOLARSHIP
Application Deadline: October 1, 2007

Name:  ______________________________________________________

 

Address:  _____________________________________________________

 

City:   ______________________  St.: _______ Zip Code:  ____________

 

Phone Number:  __________________   Email:  _____________________

 

Current Employer: ____________________________________________

Address:  _____________________________________________________

Phone:  _______________________   Starting Date:  __________________

 

Past Educational Achievement:

Dental Hygiene School Attended:  __________________________________

Date of Graduation:  ____________________________________________

Highest Degree Achieved:  _______________________________________

 

Current Educational Attendance:

Name of School:  _______________________________________________

Area of Study:  _________________________________________________

Degree Seeking:  _______________________________________________

Designate CE Course Utilization of Funds:  __________________________

 

Academy Membership:

Date first joined:  _______________________________________________

Type of Membership:  ___________________________________________

 Are you currently receiving any other scholarships?   _____YES  _____NO

 Are you using educational loans for these studies?     _____YES  _____NO

Are you a Georgia HOPE Grant recipient?                 _____YES  _____NO

Three Character References:

 1.

Name:  _______________________________________________________

 

Address:  _____________________________________________________

 

City:   ______________________  St.: _______ Zip Code:  ____________

 

Phone Number:  ________________   Occupation:  __________________

 2.

Name:  _______________________________________________________

 

Address:  _____________________________________________________

 

City:   ______________________  St.: _______ Zip Code:  ____________

 

Phone Number:  ________________   Occupation:  __________________ 

3.

Name:  _______________________________________________________

 

Address:  _____________________________________________________

 

City:   ______________________  St.: _______ Zip Code:  ____________

 

Phone Number:  ________________   Occupation:  __________________

  

Question: Why do you feel you need this scholarship?

 

Mail this form to:

Kathy Barlett, RDH
5810 Brookstone Walk
Acworth, GA 30101