PLEASE MAKE CHECK PAYABLE TO: 

(NOTE--Scholarship checks are only written to educational institutions, not to students)

NAME no title Mr. Mrs. Ms. Dr.

PLEASE SEND CHECK TO: 

NAME no title Mr. Mrs. Ms. Dr.

ADDRESS  

ADDRESS  

CITY, STATE, ZIPPHONE

PAYMENT REQUESTED BY

TELEPHONE NUMBER EMAIL ADDRESS  

ALLIANCE: 02 TAME, Inc. 30 Amarillo 28 BCAME 10 Capital Area 12 DAME 46 ETAME 22 FAME (Ft. Worth) 18 Four Corners 20 GCAME (Golden Crescent/Victoria) 06 GCTAME (Gulf Coast) 16 GTTAME 24 Lubbock 26 Midland 36 Odessa 04 Rio Grande Valley 08 SAAME 42 Waco 32 Wichita Falls (the account from which these expenses are to be paid)

REASON FOR PAYMENT:

PAY FROM: Unrestricted Funds Scholarship Funds Program Funds Memorial Fund                                    AMOUNT: $

* IF SCHOLARSHIP, INDICATE SOURCE (DONOR COMPANY OR INDIVIDUAL):

For which semester/yr should this scholarship be applied? 

Student's name: Student's SS#:

 Alliance signature:                                                                              State office approval:     

__________________________________________________           __________________________________________________           

AUTHORIZED ALLIANCE SIGNATURE                                                   AUTHORIZED SIGNATURE (FOR STATE OFFICE USE)
DATE:                                            DATE: