MILLWRIGHT LOCAL NO. 1755
SCHOLARSHIP PROGRAM APPLICATION FORM
Applicant’s Name: _____________________ Social Security No: __________________
Address: ___________________________ Telephone No: ( ) __________________
City, State, Zip Code: ____________________________________________________________
Date of Birth: ___________________________ Age: ______________________________
School/University: _________________ Enrolled: _______ Date accepted: ___________
Address: __________________________________________________________________
City, State, Zip Code: ____________________________________________________________
Applicant is the son, ____, daughter ______, other legal dependent ______ of a Millwright Local No. 1755 member in good standing.
__________________________ _____________________________
Date Applicant’s signature
CERTIFICATION
Member’s Name: _____________________ Social Security No: __________________
Address: ___________________________ Telephone No: ( ) __________________
City, State, Zip Code: ____________________________________________________________
How long a member? ________________
I certify that I am a member in good standing of Millwright Local Union #1755 and have been for at least one (1) year prior to the date of this application. I further certify that the above-noted applicant is my son, daughter or other legal dependent (step child) and has been accepted or is enrolled in a program at an institution of higher learning as noted above.
__________________________ _____________________________
Date Member’s signature
NOTE: This application must be received by Local Union #1755 on or before May 1, 2010. A Copy of an acceptance letter from the school must be attached.