
Type or print in black ink all information requested. This original form must be submitted to the Scholarship Committee Chair. Additional sheets should be used to answer the questions.
I hereby apply for a scholarship.
Check one: Level 1 _____________ or Level 2 ________________Scholarship
NAME_____________________________________________________________________________
Last First Middle
ADDRESS________________________________________________________________________
Street Address
________________________________________________________________________________
City State Zip
Phone # _______________________ E-mail ____________________________________________
BIRTHDATE________________________________
Month Day Year
DATE OF HIGH SCHOOL GRADUATION ________________________________________________
REQUIRED FOR LEVEL 2 APPLICANTS ONLY: Institution of higher education currently attending:
_______________________________________________________________________________
I have held continuous membership in the American Fuzzy Lop Rabbit Club since _________________
Month/Year
Applicant attestation
I hereby apply for a scholarship under the requirements listed and submit that the preceding information is accurate to the best of my ability.
_____________________________________________ __________________________
Applicant signature Date
Submit completed application to:
Amy Arata
AFLRC Scholarship Chair
607 Bald Hill Road
New Gloucester, ME 04260
amy_arata@yahoo.com