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    Susan Brokaw Kimmons Memorial Scholarship. Tioga County Home Bureau Scholarship. Part B: STUDENT INFORMATION. Name: ID#: E-mail: Local Address: Permanent Address: Local Phone: Permanent Phone: Year in School (check one): Freshman Sophomore Junior Senior.
|[pic] |HSHP Scholarship Application 2012-13 | | |Department of Occupational Therapy | | |(all information must be typed and a current resume must be attached) |

Part A: Application: (Check the scholarship that you are applying for. REMEMBER, Separate application forms must be completed and signed for each scholarship. Part E of this application must be specific to the scholarship that you are applying for)

| |Department Scholarships | | |Charles A. Frueaff Foundation Scholarship | | |Arkell Hall Foundation Scholarship | | |Susan Brokaw Kimmons Memorial Scholarship | | |Tioga County Home Bureau Scholarship |


|Name:       |ID#:       |E-mail:       |

|Local |      | |Permanent |      | |Address: | | |Address: | | |Local |      | |Permanent |      | |Phone: | | |Phone: | |

|Year in School (check one): Freshman Sophomore Junior Senior | |Major:       |Specialty/Minor:       |Academic Advisor:       | |Total credits earned to |Credits currently enrolled |Expected Graduation Date:       | |date:       |in:       | | |Current GPA:       | | |

Part C: Academic Honors:

(include a brief description any grants, scholarships and/or awards that you have received)


Part D: Summary of Extracurricular Activities: (include campus activities, community service, and offices held)


Part E: What makes you a good candidate for this scholarship?


Part F: OPTIONAL RELEASE of INFORMATION Members of the HS&HP Student Board of Advocates have asked if the names of the award winners could be posted on the scholarship website. Please indicate below if you would agree to have your name posted should you receive the scholarship. Whether or not you agree will NOT affect the selection process.

If you consent, please check: If I receive this award, you have my permission to post my name on the HS&HP scholarship website


My signature below indicates that I have completed the application personally and that the information provided is complete and truthful.

Student Signature ____________________________________________________ Date __________

Completed applications must be submitted to the HS&HP Deans Office (320 Smiddy Hall) on or before 4:00 pm on Friday, March 9, 2012. Remember that your resume needs to be attached to this application.