Sean Anderson Memorial Scholarship Program
APPLICATION FORM (2005)

This form to be completed and mailed to:
SpeechEasy, c/o Sean Anderson Memorial Scholarship, 112 Staton Road, Greenville, NC  27834

  PLEASE NOTE:
  • Read Sean Anderson Scholarship Program “Information Sheet” prior to completing this form.
  • Application must be typed or printed clearly.
  • The completed application form, essay, proof of residency and proof of household income must be received no earlier than February 1, 2005 and no later than March 1, 2005.
  • Only one (1) application per applicant may be submitted.  Duplicate application submissions will result in disqualification.
  • All required information must be sent in one package.
  • Failure to follow instructions and properly complete application will result in an incomplete form and will not be considered by the selection committee.

 

Applicant:  __________________________________________________________________________
                                  (Last Name)             (First Name)             (Middle Initial)

Date of Birth: ____________________________________            Male             Female
                                           Month/Day/Year

Parent or Guardian: _________________________________________________________________
                                                (Last Name)                           (First Name)

Relationship to Applicant: ____________________________________________________________


Permanent Address:    _______________________________________________________________

City:____________________Zip Code:  ________ Country: ___________________


Mailing Address (if different): _________________________________________________________


Home Phone:  _________________________ Email address: _______________________________


Total Household Income: $______________________
 Own       Rent
                          Per Year
 Please include copy of homestead exemption card
OR lease/rental agreement

Source(s) of Income: ______________________________________________________________
Please include copies of W-2(s) and Most Recent Federal Income Tax Return

 

Date of Applicant’s Evaluation by SpeechEasy Provider: ___________________________________
 
                          Month/Day/Year

 

Certified Speech Language Pathologist (SLP) and SpeechEasy Provider that performed
evaluation: _________________________________________________________________________________________
 ( Complete Name of SLP and SpeechEasy Provider )

 

Signature of Parent or Guardian: ________________________________ Date: _______________  

Disclaimer:  By signing, Parent or Guardian for recipient certifies that information provided is true and complete, also, agrees to have their names and/or photographs published in conjunction with the award of the device, and with any promotion of the Sean Anderson Memorial Scholarship Program.		  

www.speecheasy.com
Telephone: 877-4FLUENCY

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