Scholarship Disbursement Request -- Tuition

Scholarship Extension Form

Tuition Expenses Only -- Please use this form for both Outstanding Teen and Miss Tuition Scholarship Requests
Scholarships will cover only tuition, on-campus room/board as explained in our Scholarship Rules and Regulations. Please see your original Scholarship Rules and Regulations that was completed when you became a candidate for our program for complete rules on scholarship redemption and applicable time lines involved.

Receipts / Invoices must be attached for reimbursement.

If the form is not fully completed we will not be able to process your request. Requests can take one to four weeks to process. Please plan accordingly. It is your responsibility to follow up upon submission of form to verify reimbursement status.

For questions on this form please contact Jennifer Marshall at MPCTreasurer@gmail.com
Candidate Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Requesting Scholarship for Program Year*
Enter year you competed and earned scholarship
Name of college / institution attending / attended*
Address of college / institution*
I was / am registered and accepted as a:*

part-time studentfull-time student
Dollar amount of expenses requested for disbursement*
Please make check payable to: (Note we will only issue reimbursement to candidate directly for qualified expenses for which you have already paid, otherwise college / institution will be paid directly) *
Please enter full mailing address
Attach invoices, receipts, loan statements below.*

Cancelof
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Scholarship Extension Form