Harriet Bloomfield Memorial Scholarship

APPLICATION FORM

Name ______Address______City______State______Zip______Work Phone______Home Phone______Email:______School______Degree______Anticipated Graduation Date______

AUTHORIZATION FOR RELEASE OF INFORMATION

The NASW-NJ is pleased to have the opportunity to honor our scholarship recipients. We would like to highlight the important contributions you are making to the social work profession.

By signing below you will authorize NASW-NJ to post, on the Chapter’s web site and in various publications including the FOCUS, biographical information that you included in your application for a scholarship. Your name as a scholarship recipient is a matter of public record.

By signing below, (please check one)

___I permit the NASW-NJ to print biographical information, in addition to my name and school, on the NASW-NJ Chapter web site and in various publications.

___I understand as a scholarship recipient that my name and school may be used in administrative and other reports or publications released from NASW-NJ and NASW. I do not permit the Chapter Office to distribute any additional information.

______(Signature) (Date)

______Name (please print)

NASW-NJ 30 Silverline Drive, Suite 3 North Brunswick, NJ 08902 Fax: 732-296-8074