Faculty Scholarship Chair Sign-off
Albert E. Carlotti Dental Hygiene Scholarship
Instructions: Complete this form, sign and date it, and return the form along with 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 (x7159)
Name________________________________________ Student I.D. #_____________________________
Address_____________________________________ City___________________ State_____ Zip_______
Telephone______________________________________ email___________________________________
1. Will the selected recipient be graduating from the Dental Hygiene Program? Yes__ No__
2. Is the selected recipient a member of the Student Dental Hygiene Association? Yes__ No__
3. Has the selected recipient demonstrated outstanding leadership qualities? Yes__ No__
4. Has the selected recipient fully completed the application form? Yes__ No__
. Is the selected recipient a U.S. citizen? Yes__ No__
. The selected recipient meets all the scholarship eligibility requirements. Yes__ No__
Comments:
How many applications were received? ______
Who was on the selection committee?
_______________________________
_______________________________
_______________________________
Who will be presenting the award at Class Night?_________________________
___________________________________________
Director of Dental Hygiene’s Signature / Date
