FLORIDA FOUNDATION OF DENTAL HYGIENE ADVANCED DENTAL HYGIENE DEGREE SCHOLARSHIP APPLICATION FORM Name _________________________________________________________________________________ Address ___________________________City ________________________State ______ Zip __________ Home Phone  (________)________________________Work Phone  (_________)_____________________ If currently employed, what is your occupation and salary? _______________________________________ ______________________________________________________________________________________ College now attending ______________________________________ Current GPA ___________________ Previous education (include name of institution, location, year(s) attended or graduated, degree obtained): ______________________________________________________________________________________ ______________________________________________________________________________________ Are you listed as someone’s financial dependent? ______________ Do you have financial dependents living with you? _____________ How many? ______________________ If you are a financial dependent, please complete the following: Financial Supporter’s Name _________________________________________________________________ Address ___________________________________City _________________State ______ Zip ___________ Occupation _______________________________________ Annual Salary ____________________________ Are there other dependents in this household? ________How many? _______________ Have you received financial aid from other sources?  ___________If yes, please specify: __________________ _________________________________________________________________________________________ Is there anything else you feel this Foundation should know when considering your application?_____________ __________________________________________________________________________________________ On a separate sheet of paper please list all ADHA/FDHA participation.  Also please explain how additional education will benefit you in your role as a dental hygienist and tell us where you plan to practice after completing your degree and why. I attest to the best of my knowledge that all of the above information is correct. Applicant’s Signature __________________________________________Date ________________________ COMPLETED APPLICATIONS MUST BE RECEIVED BY SEPTEMBER 1 (Each school year) Send original application and 3 copies to:               FFDH c/o Lisa Potter P.O. Box  1285 Palmetto, FL 34220