Ga Scholarship Nomination Form

GENERAL ASSEMBLY SCHOLARSHIP NOMINATION FORM INSTRUCTIONS: Lwislators, please complete this form. Send the oriainal too two sheets to the a b w e address and retain the third cow for vour files. The original Waiver of Confidentiality" form must accompany this nomination form in order for the scholarship to be processed.

I hereby nominate and appoint:

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Nwnedcnaimwe Smrsf Address

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Social SecuMy Numb

who is certified to b e a resident of my district for a scholarship at*

as provided in an Act of the General Assembly of lllinois approved in 1961, as amended. I desire the above individual to have my

scholarship to begin Term (Fall,Spring. SummerINw

Year of Schdmhip (If Vacated. -1

1 Year Including Summer 1 Year Exduding Summr [7Summer Only Other (7fFiImgaVacaiedSems?wJ

'Check one of the followinglnrfitutions: Chicago State University Eastern lllinois University Governors State University IllinoisState University Northernlllinois University Northeastern IllinoisUniversity Southem lilinois University, Carbondale Campus [7 Southern lllinois University, EdwardsvilleCampus University of Illinois, Chicago University of lllinois, Springfield University of lllinois. Urbana Western lllinois University

LegirIaBPs Name (Rint a T w )

Senatorial District Number OR Representat'w D i i d Number

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. .. ..~ . . -.OFFICE~SE.ONLY

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Receive4 Recorded and Forwarded to: 20

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