MEYHM Family Foundation

Assistantship Application Form

(Please Print; all fields must be filled in)

Section 1:                              Personal Information

Name:   ____________________________          Home Phone:______________  Cell Phone:______________                     

Email (1):_______________________________  (required) Email (2):_____________________________ (optional)

Current Address:___________________________________________________________________________________

                                   street                                  apt number                                city                          state       zip code

Number of Years at this Address: ________ Provide prior address below if at current address less than 3 years 

Prior Address: ____________________________________________________________________________________

                                   street                                  apt number                                city                          state       zip code

Residency / Citizenship Status: _________________________        Social Security No: ______________________

Sources of Financial Assistance: 1. _____________________________                    2. _____________________________

               (List, if any)

Prior Year’s Gross Income:    $___________   Attach copy of last year’s Form 1040 or other income tax return

Section 2:                Contact Information for Individual Submitting Application

Name:   ____________________________          Home Phone:______________  Cell Phone:______________                         

Home Address:___________________________________________________________________________________

                                   street                                  apt number                                city                          state       zip code

Email (1):_______________________________ (required)     Email (2):_____________________________ (optional)

Section 3:                       Basis for Request for Financial Assistance

Instructions:  Please provide a detailed explanation of the basis for the request for financial assistance, in accordance with the guidelines attached to this application form.

______________________________________________________________________________

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Section 4:                                           Certification

Applicant certifies the information provided above is accurate to the best of his/her knowledge.

Signature of Applicant: _____________________________________  Date:________________

                           (Parent’s signature required, if applicant is not 18 years or older)