Application Form

ABRAHAM CHATMAN SCHOLARSHIP

at Cornell University

Applicants must meet all of the eligibility requirements as outlined by the Rochester Regional Joint Board Scholarship Advisory Committee.

Applicants MUST, in addition, file an application to Cornell University and be accepted in order to be eligible.

Important: This application must be returned by January 2, 2008, to:

SCHOLARSHIP ADVISORY COMMITTEE

Rochester Regional Joint Board, UNITE HERE

750 East Avenue, Rochester, NY 14607

Applicant's (Student's) Name ___________________________________________________

Please Print

Applicant's (Student's) Social Security Number ___________________________________

Address _____________________________________________________________

Street City & State Zip

Address of High School ______________________________________________

Member's Name ____________________________________________________

Member's Clock Number _________ Member's S.S. # ___________________

Member’s Present Employer _________________________________________

Member’s Home Address ____________________________________________

Member’s Home Phone _____________________________________________

Area Code Phone Number

If work phone is OK to call, please complete information below

Member’s Work Phone ______________________________________________

Area Code Phone Number