The Jack Gargalino Memorial Foundation Scholarship Application Form

Family Information
Name of Mother or Guardian (applicant under 18)

First NameLast Name
Mother's Job/Position (applicant under 18)
Address of Mother (applicant under 18)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Father (applicant under 18)

First NameLast Name
Father's Job/Position (applicant under 18)
Address of Father (applicant under 18; if not the same as above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is anyone in your immediate family an active or retired member of law enforcement?

Yes (Please elaborate in box below)NoOther
If "Yes" to above, please indicate which family member(s) and where they served

Financial Information
Are you a dependent of your Parents?

YesNo
Your Family's Joint Annual Income
Have you tried applying for scholarships with other organizations previously?

YesNo
Have you been awarded any other scholarships as of the date of this application?

YesNo
Any information that might support your answer above

I AFFIRM THAT ALL STATEMENTS I HAVE INDICATED HEREIN ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. ANY MISREPRESENTATION I HAVE MADE CAN CAUSE FOR THE INVALIDATION OF MY APPLICATION AND SHALL BAR ME FROM RE-APPLYING FOR THE SAME.
Applicant's Signature

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Name of Applicant

First NameLast Name
Date Signed by Applicant

MonthDayYear
Date
Phone Number

Area CodePhone Number
Attachments
Attach Typewritten Essay

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Attach Letters of Rec.

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The Jack Gargalino Memorial Foundation Scholarship Application