LOIS K. SOLOMON SCHOLARSHIP AWARD APPLICATIO

LOIS K. SOLOMON SCHOLARSHIP AWARD APPLICATION

Name:________________________________________________________

Address:_______________________________________________________

Telephone:______________________

City:_______________________ State: _____ Zip: ___________________

College:________________________________________________________

Address:_______________________________________________________

Telephone:_____________________________________________________

City:______________________________ State: _____ Zip:______________

Anticipated date of graduation:_____________________________________________________

GPA in courses toward Dental Assisting degree:_________________________

Describe any scholarship awards or loans you have received:

______________________________________________________________

Extra curricular activities:

______________________________________________________________

Community involvement:

______________________________________________________________

Honors or awards:

______________________________________________________________

Describe your strengths which will contribute to success in Dental Assisting:

______________________________________________________________

Describe your professional goals, including how obtaining this scholarship will help in achieving your goals:

______________________________________________________________

List work experience (related to the health care profession):

______________________________________________________________

I authorize investigation on all statements contained in this application. I understand that misrepresentation or omission of facts is cause for disqualification. I also understand that I will accept this scholarship with the condition that it be used for the study of dental assisting. Any other use will constitute a refund to TDAA.

Signature ___________________ Date _

(TWSP2008)

Signature ___________________________ Date _________

Signature ___________________ Date _