Complete and return this form by July 15, Address: City: State: Zip code: Telephone (Day): Telephone (Evening): Telephone (Cell):

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1 Applicatin Frm Edward T. Cnry Memrial Schlarship Prgram & Jean B. Cryr Memrial Schlarship Prgram Cmplete and return this frm by July 15, Sectin A: General Infrmatin (Please Print) Last name: First name: MI: Scial Security Number: Address: City: State: Zip cde: Telephne (Day): Telephne (Evening): Telephne (Cell): E mail address: Are yu a Maryland resident? Yes N Have yu applied fr this schlarship in the past? Yes N Year applied: Please check ne that applies: Sn r daughter f members f the United States armed frces wh died as a result f military service, r wh suffered a service cnnected 100% permanent disability as a result f military service Veteran wh suffers a service cnnected disability f 25% r greater as a result f military service, and has exhausted r is n lnger eligible fr federal veterans educatinal benefits POW/MIA f the Vietnam Cnflict Sn r daughter f POW/MIA f the Vietnam Cnflict Sn, daughter, r surviving spuse (wh has nt remarried) f a victim f the September 11, 2001, terrrist attacks wh died as a result f the attacks n the Wrld Trade Center in New Yrk City, the attack n the Pentagn in Virginia, r the crash f United Airlines Flight #93 in Pennsylvania Sn, daughter, r surviving spuse (wh has nt remarried) f State r lcal public safety emplyees r vlunteers wh died in the line f duty Sn, daughter, r surviving spuse (wh has nt remarried) f State r lcal public safety emplyees r vlunteers wh sustained an injury in the line f duty that rendered the public safety emplyee r vlunteer 100% disabled State r lcal public safety emplyees r vlunteers wh became 100% disabled in the line f duty Sn, daughter, r surviving spuse (wh has nt remarried) f a schl emplyee wh, as a result f an act f vilence, either died in the line f duty, r sustained an injury in the line f duty that rendered the schl emplyee 100% disabled NOTE: Public safety emplyee r vlunteer must have been a resident f Maryland at the time f death r when declared 100% disabled.

2 Applicatin Frm Edward T. Cnry Memrial Schlarship Prgram & Jean B. Cryr Memrial Schlarship Prgram Sectin B: Family Infrmatin The fllwing infrmatin pertains t the family member wh was killed as a result f military service in the United States armed frces; r, as a result f service as a State r lcal public safety emplyee r vlunteer; r wh suffered a service cnnected 100% permanent disability as a result f military service; was a victim f the September 11, 2001 terrrist attacks; r was killed r 100% disabled due t an act f vilence as a schl emplyee. Scial Security Number f persn killed r disabled: Last name f persn killed r disabled: First name: MI: Relatinship f applicant t persn killed r disabled: Branch f United States armed frces r name f public safety facility in which persn killed r disabled served, if applicable: Date f death r disability: / / Address at date f death/disability: City: State: Zip cde: Are yu currently receiving any ther student financial aid funds because yu are the child r spuse f a victim f the September 11, 2001 terrrist attack? Yes N If yes, please list schlarship name(s) and amunt(s): $ $ $

3 Applicatin Frm Edward T. Cnry Memrial Schlarship Prgram & Jean B. Cryr Memrial Schlarship Prgram Sectin C: Military Persnnel (If applicable) In the case f 100 percent disabled r deceased military persnnel, and in the case f 25 percent (r mre) disabled military persnnel, please, using a separate sheet f paper, explain the circumstances f the death r disability, the cause, and why it is cnsidered service cnnected. **T be cmpleted by the Veterans' Administratin ffice. In the case f 100 percent disabled military persnnel: (name f disabled persn) Cde(s): has a 100 %* disability rating, and his/her diagnstic cdes are: Percentage(s): *Veterans must be classified as 100% disabled (i.e., cannt be 90% disabled, but 100% unemplyable). In the case f 25 % (r mre) disabled military persnnel: has a 25 %(r mre) disability rating, and his/her diagnstic cdes are: (name f disabled persn) Cde(s): Percentage(s): This persn has exhausted his/her federal veterans educatinal benefits. This persn is n lnger eligible fr federal veterans educatinal benefits. I hereby certify that the infrmatin prvided n this applicatin is crrect and cntained in ur recrds. Print name f authrized fficial Title Address E mail Signature Phne number City State Zip cde Date

4 Applicatin Frm Edward T. Cnry Memrial Schlarship Prgram & Jean B. Cryr Memrial Schlarship Prgram Sectin D: Public Safety Persnnel (If applicable) In the case f 100% disabled r deceased public safety persnnel, please, using a separate sheet f paper, explain the circumstances f the death r disability, the cause, and why it is cnsidered service cnnected. **T be cmpleted by the State r lcal public safety persnnel ffice. In the case f deceased r 100% disabled public safety emplyees r vlunteers: Please briefly explain hw the death r disability f was classified as a result f State r lcal public safety service: (name f deceased r disabled) This ffice is unable t prvide the requested infrmatin. I hereby certify that the infrmatin prvided n this applicatin is crrect and cntained in ur recrds. Print name f authrized fficial Title Address Signature E mail Phne number City State Zip cde Date

5 Applicatin Frm Edward T. Cnry Memrial Schlarship Prgram & Jean B. Cryr Memrial Schlarship Prgram Sectin E: Schl Emplyee (If applicable) In the case f 100% disabled r deceased Schl Emplyee, students must submit the fllwing: Using a separate sheet f paper, explain the circumstances f the death r disability, the cause, and why it is cnsidered service cnnected; and A detailed plice reprt and death certificate; r A certified letter frm the Schl/Bard f Educatin as verificatin f the emplyee s 100% disability.

6 Applicatin Frm Edward T. Cnry Memrial Schlarship Prgram & Jean B. Cryr Memrial Schlarship Prgram Required Dcumentatin Applicatins will nt be cnsidered withut the fllwing materials: Cmplete Edward T. Cnry Memrial Schlarship & Jean B. Cryr Memrial Schlarship applicatin. Cpy f yur birth certificate shwing names f bth parents if yu are the sn r daughter f a deceased r 100% disabled military persn, POW/MIA f the Vietnam Cnflict, deceased public safety emplyee r vlunteer, deceased victim f the September 11, 2001 terrrist attacks, r deceased r 100% disabled due t act f vilence as schl emplyee. Cpies may be btained frm the State Department f Vital Recrds. Cpy f yur marriage certificate (if spuse f deceased public safety emplyee r vlunteer, f deceased victim f the September 11, 2001 terrrist attacks, r deceased r 100% disabled due t act f vilence as schl emplyee). Cpy f death certificate (if deceased military persnnel, 9/11 victim, public safety emplyee, r schl emplyee). Verificatin that yu are 25% disabled frm a service cnnected disability as a result f military service and exhausted, r are n lnger eligible fr, federal veterans educatinal benefits. (Sectin C required) Verificatin that 100% disability was frm a service cnnected disability as a result f military service. (Sectin C required) Verificatin that death as a result f public safety service, r that death r 100 percent disability was in the line f duty fr a public safety emplyee r vlunteer. (Sectin D required) Verificatin that death was a result f an act f vilence in the line f duty, r the 100 percent disability was a result f an act f vilence in the line f duty fr a schl emplyee. (Sectin E required) NOTE: D nt send riginal certificate(s); they cannt be returned. All cmplete applicatins must be submitted by July 15, 2017 t: Hward Cmmunity Cllege Financial Aid Services Attentin: Edward T. Cnry Memrial Schlarship Prgram & Jean B. Cryr Memrial Schlarship Prgram Little Patuxent Parkway Clumbia, MD 21044

Complete and return this form by July 15, Address: City: State: Zip code: Telephone (Day): Telephone (Evening): Telephone (Cell):

Complete and return this form by July 15, Address: City: State: Zip code: Telephone (Day): Telephone (Evening): Telephone (Cell): Cmplete and return this frm by July 15, 2018. Sectin A: General Infrmatin (Please Print) Last name: First name: MI: Scial Security Number: Address: City: State: Zip cde: Telephne (Day): Telephne (Evening):