Legislative District 12
Senator Edward J. Kasemeyer /
Last Name First Name MI
Number and Street City Zip Code
e-mail address
SS# (Required) Home Phone Date of Birth
Marital Status: Single Married Widowed Divorced
List Parents’ names, occupations, and annual salary. Independent students complete for self, and if married, spouse:
Relationship Occupation Annual Salary
If you are a dependent student and your parents are divorced or separated, please complete the following:
Who claimed the student as a tax exemption last year:
What percentage of the student’s college expenses will the non-custodial parent pay?
According to court order, when will the non-custodial parental support for student end?
List the names and ages of dependent children/siblings in your family. Indicate the schools they are presently attending:
Name Age School
If you are a graduating high school senior, indicate your course of study and your GPA:
Advanced Academic General Vocational
SAT Scores: Math Verbal Writing
If you are presently attending college, list your GPA:
What school are you presently attending
What school will you attend in the fall?
Is the school located outside of MD?
If you are attending an out-of-state institution, please enclose a copy of the letter from the Maryland Department of Higher Education certifying their acceptance of your unique major status.
Will you be attending Full Time Part Time How many credits will you carry?
Do you now hold a degree? If yes, please list:
What major do you intend to pursue:
Briefly summarize your reasons for attending college/graduate school:
Are you employed? Full Time Part Time
Name of Employer
Briefly describe your job responsibilities:
How long have you held this job? Does employer offer tuition assistance? Percentage:
Do you intend to work this summer? Do you intend to work while attending school?
If so, indicate the approximate number of hours you will work:
Specify any other financial aid for which you have applied, its time duration and estimated amount:
Indicate below the total funds now available to you for your college/grad school education:
Pell Grant Stafford Loan
Scholarships Other Loans
Savings Winter Jobs
Veteran’s Benefits Summer Jobs
Other
Please enclose the following:
1) Copy of SAT/ACT score results (if you are a high school senior).
2) Copy of your Letter of Acceptance (if you will be entering a new school in the fall).
3) Official transcript of your most recent grades (ALL STUDENTS).
4) Unique Major opinion letter for out-of-state enrollment.
IMPORTANT NOTICE:
Failure to fully complete the application or enclose documents requested above
will disqualify you from consideration for a Senatorial Scholarship.
Are there any special circumstances of which the Scholarship Committee should be aware in order to better evaluate your financial needs?
I HEREBY AUTHORIZE THE RELEASE OF MY FINANCIAL AID FORMS to the 12th District Scholarship Committee to use in conjunction with the scholarship award process, only. All materials will be kept in strictest confidence. (If release is not signed, application will not be evaluated for award.)
Date: Signature:
Please mail to: Senator Edward J. Kasemeyer
Scholarship Committee
5205 East Drive, Suite H
Halethorpe, MD 21227
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