LOCAL 770/DHA SCHOLARSHIP APPLICATION REQUEST
C/O UFCW LOCAL 770, 630 SHATTO PLACE, L.A. CA 90005
APPLICANT’S FULL NAME
LAST FOUR DIGITS OF APPLICANT’S SOCIAL SECURITY NUMBER
MAILING ADDRESS
CITY, STATE AND ZIP
HOME PHONE CELL PHONE
RELATIONSHIP TO MEMBER (SON, DAUGHTER, PARENT, SPOUSE)
FULL NAME OF MEMBER
LAST FOUR DIGITS OF MEMBER SSN
MEMBER STORE AND STORE NUMBER
SCHOOL ATTENDING IN FALL
I AM A MEMBER/ DEPENDENT OF LOCAL 770 IN GOOD STANDING. IN ORDER TO BE ELIGIBLE FOR THE SCHOLARSHIP, I WILL REMAIN IN GOOD
STANDING FROM SEPTEMBER 2015 THROUGH SEPTEMBER 2016 AND IN THE FALL WILL BE ENROLLED AS A FULL-TIME STUDENT (12 UNITS OR MORE/
UNDERGRADUATE; 6 UNITS OR MORE/ GRADUATE).
SIGNED BY APPLICANT IN ACCEPTANCE OF THE TERMS.
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USC STUDENTS ONLY: JOSEPH T. DESILVA SCHOLARSHIP:
APPLICATION REQUEST C/O UFCW LOCAL 770, 630 SHATTO PLACE, L.A. CA 90005
APPLICANT’S FULL NAME
LAST FOUR DIGITS OF APPLICANT’S SOCIAL SECURITY NUMBER
MAILING ADDRESS
CITY, STATE AND ZIP
HOME PHONE CELL PHONE
RELATIONSHIP TO MEMBER (SON, DAUGHTER, PARENT, SPOUSE)
FULL NAME OF MEMBER
MEMBER STORE AND STORE NUMBER
LAST FOUR DIGITS OF MEMBER SSN
SCHOOL ATTENDING IN FALL
I AM A MEMBER/ DEPENDENT OF LOCAL 770 IN GOOD STANDING. IN ORDER TO BE ELIGIBLE FOR THE SCHOLARSHIP, I WILL REMAIN IN GOOD STANDING FROM
SEPTEMBER 2015 THROUGH SEPTEMBER 2016 AND IN THE FALL WILL BE ENROLLED AS A FULL-TIME STUDENT (12 UNITS OR MORE/UNDERGRADUATE; 6 UNITS
OR MORE/ GRADUATE).
I AM ENROLLED AT USC
I HAVE BEEN ACCEPTED BY USC
I PLAN TO ENROLL AT USC
SIGNED BY APPLICANT IN ACCEPTANCE OF THE TERMS.
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