Instructions: Complete this form, sign and date it and return the form along will ALL the scholarship applications to: Geraldine Peixoto, CCRI Foundation, Flanagan Campus. Upon receipt of all the applications and the sign-off form, the Office of Institutional Advancement will process the scholarship award within two weeks and mail the check to the selected recipient.

If you plan to have the award announced at Class Night and/or want the award listed in the Class Night Program Booklet, contact Jean Lovett, Office of Student Affairs at the Lincoln Campus, ext.7159.

Name _______________________________________Student I.D. # ___________________________

Address _______________________________City _____________________State ______ Zip________

Telephone ______________________________e-mail_________________________________________

1. Is the selected recipient graduating from CCRI?Yes__ No__

2. Has the selected recipient been accepted to Bryant University Yes__ No__

or

another four-year college/university? Yes__ No__

3. Has the selected recipient furnished a copy of his/her letter of acceptance? Yes__ No__

4. What is the selected recipients G.P.A.? __________

5. Does the selected recipient meet all scholarship eligibility requirements? Yes__ No__

6. How many applications were received? _____

7. Who was on the selection committee?

_________________________________

_________________________________

_________________________________

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Scholarship chair signature/date