The Thomas Washburn Memorial Scholarship
APPLICATION FORM

Applicant's Name: ________________________________________________________________________

Address: ________________________________________________________________________________

________________________________________________________________________________________

Phone No. _____________________     E-mail address   _________________________________________

High School ___________________________________________ Graduation Year __________________

Names, occupations and phone numbers of two people who will provide character references:

1. ____________________________________________________________________________________

2. ____________________________________________________________________________________

Universities and faculties to which you have applied for admittance:

Volunteer Activities. "Contribution" may be hours spent per term, period involved, achievements, responsibilities, etc.

"Contribution" may be hours spent, period involved, achievements, responsibilities, etc, for each activity.

If you need more space for ANY category you can use a separate page
OR download the printable (rtf) version and create more rows/lines as necessary.

Other relevant information: ________________________________________________________________