GEORGIA DENTAL HYGIENISTS’ ASSOCIATION

APPLICATION FOR SCHOLARSHIP

Name: _______________________________________________________________

Address: _____________________________________________________________

City: ________________________________ State: ________ Zip: ______________

Phone #: __________________ Email: _____________________________________

Dental Hygiene School: _______________________________ City: _____________

Source and amount of funds available: 

Your income: _____________________ Aid from parents: _____________________

Scholarships: _________________________ Loans: __________________________

Name of parent, guardian or spouse: _____________________ Relationship: _______

Address: ______________________________________________________________

City: ________________________________ State: ________ Zip: _______________

Company, Position held: _________________________________________________

Three written character references on separate cover (one to include Dental Hygiene Director or Clinical Supervisor). A separate recommendation form must be used for each reference.

1.

Name: ________________________________________________________________

Address: ______________________________________________________________

City: ________________________________ State: ________ Zip: _______________

2.

Name: ________________________________________________________________

Address: ______________________________________________________________

City: ________________________________ State: ________ Zip: _______________


3.

Name: ________________________________________________________________

Address: ______________________________________________________________

City: ________________________________ State: ________ Zip: _______________

Application deadline October 1, 2007. Only completed applications will be considered. Completed application should be sent to:

Community Foundation of Southwest Georgia
PO Box 2654
Thomasville, GA, 31799

Questions? E-mail Kathy Barlett