FLORIDA FOUNDATION OF DENTAL HYGIENE AS/AA 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 tell us about your SAHDA activities, what your plans are for dental hygiene practice after licensure, and how you feel this scholarship will benefit you in your role as a dental hygienist and help you achieve your educational goals. 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