All information on this form is true and complete to the best of my knowledge.

I hereby authorize the Carmine Chamber of Commerce Scholarship Committee to obtain from my school, or from any other source, such data as it may require in connection with this application, including but not limited to scores upon various tests knowing it will be held in a confidential manner by the Carmine Chamber of Commerce Scholarship Committee.

I understand that if I am granted this scholarship it is for the school year of 2019-2020. I understand payment will be made directly to my chosen educational entity and is dependent on receipt of registration affirmation being sent to the Carmine Chamber of Commerce.

I understand that failure to meet the enrollment requirements by September 30th, will be a breach of the scholarship agreement and the award will be forfeited.

I also understand that my photograph and name may be published in conjunction with recognition of receiving this scholarship.

Signature of Applicant Date

Signature of Parent or Guardian of Applicant Date