City:
State:
Zip:
E-Mail Address:
Award Amount $:
State:
Zip:
SSN:
Phone:
If a league or tournament, Certification No.:
Award date:
(Office Use Only)
CONTACT INFORMATION (Who is submitting this form)
Address:
Additional Unassigned Funds:

$
Apply Available Unassigned Funds:

$
Total Scholarships Listed:

$
Funds Submitted:

$
       
_______________________________________________________________________________________________________________
Parent/Guardian Name:
Year will or did graduate from High School:
Phone:
City:
Name:
Member ID:
RECIPIENT INFORMATION
Name:
Signature:
Street Address:
Telephone (Daytime):
Name of the Scholarship Awarded:
     
RECEIVED DATE
SUBMITTED TO SMART DATE
SMART CONFIRMATION DATE
CARSON COUNTRY USBC
YOUTH SCHOLARSHIP RECIPIENT FORM

To be submitted by Tournament or League Representative, to the CCUSBC Office for submission to SMART.
SMART Account No. 9833        SMART Account Name: CARSON COUNTRY USBC YOUTH