2008 Scholarship Awards Preliminary Application

Please complete this form and return immediately to:

Local 1262 Scholarship Selections Committee

1389 Broad Street, Clifton, NJ 07013

This preliminary application will be reviewed and processed by Local 1262. Once it is

determined that you are eligible, a long-form application will be sent to your home.

Deadline for long-form application – Tuesday, April 15, 2008

If you have questions regarding this form, please call Gladyz Rojas at 973-777-3700, ext. 223.

PLEASE PRINT CLEARLY

Last Name: __________________________ First Name: _________________________

Street Address: _______________________________________________________________

City: _________________________________ State: _____ Zip: _____________

Telephone: ___________________________ Social Security #: ____________________

I am a Local 1262 Member _____ Yes _____ No

I am employed by (name of store): ________________________________________________

Store Address: _______________________________________________________________

Store Number: ________________________ Department: ________________________

I am related to a Local 1262 Member _____ Yes _____ No

Member’s Name: _____________________________________________________________

My relationship to the member (son, daughter): _____________________________________

Member’s Mailing Address: _____________________________________________________

City: _________________________________ State: _____ Zip: _____________

Name of Member’s Store: _______________________________________________________

Store Address: _______________________________________________________________

Store Number: ________________________ Department: ________________________

Member’s Social Security Number: _______________________________________________

I will graduate from high school (month and year): ____________________________________

If you are a college student, please indicate highest academic level to be completed by August

this year: _____ Freshman _____ Sophomore _____ Junior

I wish to apply for a Local 1262 Scholarship Award. I understand that the decision of the Local 1262

Scholarship Awards Committee will be final and agree to abide by this decision.

Signature: _________________________________________ Date: ________________