Applicant Information

Name:__________________________________________________

Address:________________________________________________

City:____________________________ State:____________ Zip Code:___________

Day Time Phone ( )________________ Evening Phone ( )________________

Applicant’s affiliation with the Fire Company

Member Parent/guardian is a member Resident of the Service Area

College 1 2 3 4

Total college credits completed ____________

Address _______________________________________________________

City ______________________ State _____________ Zip Code ________

Field/course of study____________________________________________

Matriculated Course Yes No

Semester Dates (That scholarship will be applied to)____/______ to ____/______

Degree Pursuing Associates Bachelors Masters Doctorate

Number of credits completed at institution _______________________________

Number of Semesters completed at institutions ___________________________

Address ___________________________________________________________

City_______________________ State__________ Zip Code_________________

Phone ( ) _________________

Address ___________________________________________________________

City_______________________ State__________ Zip Code_________________

Phone ( ) _________________

Agreement Application & requested materials must be postmarked by 6/30/09

I declare that all statements in this application are complete and correct to the best of

my knowledge, I agree to abide by the scholarship rules set forth by the East Greenbush

Fire Co. or will forfeit my scholarship eligibility and benefits.

Applicants Signature_________________________________ Date: ________________