<p> Harriet Bloomfield Memorial Scholarship</p><p>APPLICATION FORM</p><p>Name ______Address______City______State______Zip______Work Phone______Home Phone______Email:______School______Degree______Anticipated Graduation Date______</p><p>AUTHORIZATION FOR RELEASE OF INFORMATION</p><p>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.</p><p>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.</p><p>By signing below, (please check one)</p><p>___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.</p><p>___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. </p><p>______(Signature) (Date)</p><p>______Name (please print)</p><p>NASW-NJ 30 Silverline Drive, Suite 3 North Brunswick, NJ 08902 Fax: 732-296-8074</p>