MAIL TO:		THE AMERICAN LEGION
			DEPARTMENT OF NEW HAMPSHIRE
				25 CAPITOL ST RM. 431
				CONCORD NH 03301-6312
	RAYMOND K. CONLEY MEMORIAL SCHOLARSHIP									$500.00
Please provide the following information:
NAME
		(LAST)		(FIRST)		(MIDDLE INIT.)				(AGE)
ADDRESS ___________________________________________________________________________________________
		(STREET OR P.O. BOX)					(CITY, STATE, ZIP CODE)
TELEPHONE _________________________________					RESIDENT OF NEW HAMPSHIRE ______				YEARS
NAME OF PARENT OR GUARDIAN YOU LIVE WITH _________________________________________________________
EMPLOYER & EMPLOYMENT			FATHER
			MOTHER
TOTAL HOUSEHOLD INCOME BEFORE DEDUCTIONS $ _______________
NUMBER OF YOUNGER CHILDREN IN YOUR FAMILY ________
NUMBER OF FAMILY IN COLLEGE OR POST SECONDARY SCHOOL NEXT YEAR ___________
COLLEGE EXPENSES:					ANTICIPATED RESOURCES:
Tuition and Fees		$			Parents Contributions		$
Room and Board		$			Scholarship & Grants		$
Books and Supplies		$			Your Contribution		$
Personal		$			College Work Study		$
Travel/Commuting		$			Other (Specify)		$
Others		$			____________________________________
	TOTAL	$				TOTAL	$
** APPLICANT MUST SUBMIT THE FOLLOWING INFORMATION WITH THIS APPLICATION
1.	Must show acceptance to a four (4) year college or two (2) year vocational school
2.	Must be for a career in Physical or Mental Rehabilitation area.
3.	A resume to include such information as educational background, all school and outside activities,
	need, and other information you feel is important.
4.	A transcript of high school grades for Junior and Senior years, showing at least a "B" average.
5.	At least two (2) letters of endorsement, (i.e.  Teachers, Principal or other prominent members
	of your community).
6.	Must be a resident of New Hampshire at least three (3) years.
	WE CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND ACCURATE.
	Students Signature						Parent or Guardian Signature
		**  APPLICATION MUST BE POSTMARKED NO LATER THAN MAY 1st  **