COLUMBUS FORUM EDUCATORS' LODGE #1492

College Scholarship Application 2010

Qualifications:

* Only High School Seniors may apply
* Applicant must have an overall average of 3.0, B or 85
* Applicant must be a child or grandchild of a Columbus Forum member

Important Documents:
* High School Transcript
* Final Junior grades
* SAT scores

______________________________________________________________________

Applicant ______________________________________________________________

Date of birth  _____________________                 Phone Number __________________

Address  _________________________City ________________State__________Zip____

Name of High School _______________________________________________________

Address of School __________________________________________________________

College Applicant Plans to attend_________________ Course of Study _______________

Name of Columbus Forum Member ____________________________________________

Relationship to applicant ____________________________________

Date___________  Signature of Applicant __________________________________

Date __________  Signature of Lodge President _____________________________

Mail to: Dr. Marylouise DeNicola
President, Columbus Forum Lodge
2340 S. 16th St.
Phila. PA 19145

                       Application and material must be returned by March 1st.

COLUMBUS FORUM LODGE 1492
2010 DUES STATEMENT

                               Please return by March 15th

 Member with $100.00 Insurance------------------------$35.00

Member with $500.00 Insurance------------------------$45.00

Retired Member with $100.00 Insurance-------------$35.00

Retired Member with $500.00 Insurance-------------$45.00

Associate Member with no Insurance-----------------$35.00

 Please make check payable to the Columbus Forum Lodge 1492

 Please complete so we can update our records and return to:

                                        Dr. Marylouise DeNicola
                                             2340 S. 16^th Street
                                         Philadelphia, PA  19145

Name __________________________________________________

Address ________________________________________________

 ________________________________________________

 ________________________________________________

 Phone ____________________________________

 Position _______________________________________________

 Insurance Policy Amount ______________DUES_____________

 Beneficiary_____________________________________________