Student Scholarship Application
Address: 1020 W. Olive Ave., Burbank, CA 91506
Phone: (818) 238-2950  •  Fax: (818) 238-2979

Student's Member Account Number:
Student's First Name: Middle Name/Initial: Last Name:
Street Address: City: State: Zip Code:
Home Phone #: Cell Phone #: Parent or Guardian Name:
Student Email Address:
I Don't Have An Email Address
Birthdate In August 2014, I will Be A:
College Freshman College Sophomore
College Name: City: State:
Employment - Name Of Company: City: Weekly Hours: Start Date: End Date:

       xx/xx/xxxx xx/xx/xxxx
School & Community Activities/Awards:
Educational Goals/Objectives & Major:
 

STATEMENT OF INTENT

I HEREBY AFFIRM that I am currently attending, or intend to enter an accredited institution of higher learning as a full-time student for the fall 2014 term. I hereby grant permission for use of my name and/or photograph in future publicity for the Media City Community CU Member Scholarship program.
Your application file will not be complete until Media City Community CU receives your completed application, all applicable official transcripts, a recommendation from a community member and a recommendation from teacher or administrator.
I Affirm   I DO NOT Affirm