Hagan-Perry Family Association

Scholarship Application

The Hagans-Perry Family Association will award scholoraships to eligible family members.

Applicant Name (Last)________________(First) __________________ (Middle) ______

Permanent Address (City) ______________________ (State) ________________ (zip)_________

Telephone Number (s) (Home)___________________ (Work/School) _____________ (fax)____________________ (email) ______________________________________

School Presently Attending __________________________ Classification

Anticipated Graduation Date ______________ Degree Pursuing____________

Father (name) ____________________ Mother (name) _________________________

Are you a member of the Hagan-Perry Family ?  Yes____ No___

STATEMENT OF AGREEMENT

If I receive this scholarship, I agree to submit proof of enrollment to the Scholarship Chairperson within one month of my enrollment.

Signature _____________________ Date_____________

Return Application to: Mr. Cardell Gunn

              Scholarship Committee Chairperson

3644 Stonewall Manor Dr.

Triangle, VA 22172

Applications must be postmarked by 31 Jan

To be completed by Scholarship committee

_________________________________________________

Date Received ____________________ Date Postmarked______________________

Application Completed? ________Yes ________No   Reviewer's Initials _______