pdf for scholarship - Blandin Foundation

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2012-13 Applicationalso available at www.blandinfoundation.org1. Name Maiden Name (if married)(last) (first) (m.i.)Race/Ethnicity2. Student Email Address African American/Black Asian Pacific Islander Native American(please print) Hispanic/Latino Caucasian Do not wish to provide3. Daytime Phone Other, please specify4. Permanent Address(street) (city) (county) (state) (zip)5. Date of Birth 6. Social Security Number7. High School Attended Graduation Date8. College/Technical College (2012-13)Institution Address(please notify us immediately if you change schools)How many years will you have completed at a post-secondary institution as of June 2012?Have you received a baccalaureate degree? Yes No9. Please check appropriate box for 2012-13 school year: Dependent living on campus Dependent living off campus Dependent living with parents (or other relatives) Independent student10. When do you plan to graduate from post-secondary school: Month Year11. How did you hear about this Blandin Foundation program?12. Father’s, Guardian’s or Spouse’s NameEmployerAddressMother’s or Guardian’s NameEmployerAddress13. Other Siblings in College/Technical College(Do not list family members that are considered independent or are enrolled in thePost-Secondary Education Option (PSEO) Program)Financial Information14a. Parents: Cash (Savings & Checking) $ Trust Fund $ CDs $Stocks/Bonds/Mutual Funds $ Education IRAs $14b. Students: Cash (Savings & Checking) $ Trust Fund $ CDs $Stocks/Bonds/Mutual Funds $Parents: do not include employer 401(k) plans, pension plans, or IRAs.15. List any other scholarships, grants or aid you have been awarded for the institution, minority aid programs,service organizations, etc. for the 2012-13 school year and keep us informed of any changes or additions to this list.A.B.C.$ Amount(continued on back)
Unusual circumstancesAre there unusual circumstances that have a direct impact on your financialneed? Has your family experienced a drop in income in recent months due toloss of employment, divorce or death? Has your family experienced high outof-pocketmedical costs during the past year? Part-time scholarships (6-11credits) are also available to those applicants with unusual circumstances, suchas illness, courses not offered during a specific semester/quarter or work-relatedissues. Therefore, if you plan to be enrolled part-time, or have experiencedother unusual circumstances, additional paperwork must be completed andreturned to the Blandin Foundation. Please contact Diana Daigle at the Foundationoffice (218) 326-0523 or email: scholarships@blandinfoundation.org.Your situation will be taken into consideration when award decisions are madeduring the last week of June.Remember to mail a copy of your 2011 federal tax return and a copy of yourparents’ (for dependent students) 2011 federal tax return (form 1040, 1040Aor 1040EZ). If your family owns a business, please include the appropriateschedule for that particular business/corporation, Form K-1/subcorp. If yourfamily operates a farm or has experienced high medical costs, include SchedulesA and F. Please do not send us your Minnesota state income tax form.Questions?Call Diana Daigle at (218) 326-0523 or email:scholarships@blandinfoundation.orgCertificationIn submitting this application, I certify that the information provided is completeand accurate to the best of my knowledge. Falsification of information mayresult in termination of any scholarship granted.DateSignature100 North Pokegama AvenueGrand Rapids, MN 55744 USA(218) 326-0523(218) 327-1949 (fax)email: scholarships@blandinfoundation.orgwww.blandinfoundation.org
Page 1 and 2: 2012-13Education AwardsOVER 19,000
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Page 12 and 13: 2012-13Student Release FormBLANDIN
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