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Print out the Latreese Nicole Fagan Scholarship Memorial Fund Application Form.  Complete the requested information and send it to the address below. A person may nominate someone for this scholarship.  The application process can be initiated by the person who has lupus or a non-relative nominating a person with lupus.

You may also request an Application Form by writing, e-mailing or calling:

FOR 2004-2005 ACADEMIC YEAR COMPETITION:

Available funds of $1,000 for individual awards.  Money is to be used to cover tuition, books, fees, room and board.  Funds will be made payable to the accredited institution of higher learning.

LNFMSF - Accepting Scholarship Application:
Start Date: October 1, 2004
End Date:  March 31, 2005

	Last Name:			Social Security Number:				--
	First Name:
	Middle:			Date of Birth:				//
						(mm/dd/yyyy)
	Street  Address:							Apt:
	City:			State:				Zip:
	Phone (Day):		()--	Martial Status: Single Married U.S. Citizen: Yes No
	Phone (Eve.):		()--
	Fax:		()--
	Email:

Last Name:

Phone (Day):

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First Name:

Phone (Eve.):

()--

Middle:

Fax:

()--

Street Address:

Apt:

City:

State:

Zip:

Physician's Last Name:

Office Phone:

()--

Physician's First Name:

Office Fax:

()--

Office Address:

Suite:

City:

State:

Zip:

Please attached additional sheets if space provided below is insufficient.

Signature:

Date:

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	High School Name:
	Street Address:						Apt:
	City:			State:			Zip:
	Telephone:		()--
	Date of Graduation:		//