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MMEA Legacy Scholarship

Contact Information

Name of person completing this form:(Required)

First Last

Email contact for the person completing this form:(Required)

Donor Information

Name of Donor(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Address of the Donor of record.

Email(Required)

Email for the Donor of record. Enter N/A if the donor does not have email access.

Phone

Primary phone number for the Donor of record.

Does the donor wish to remain ananymous?(Required)

YES

Are there multiple donors for this scholarship?

YES

If yes, please provide the names of the other donors associatied with this scholarship:

Legacy Scholarship Information

For whom is this scholarship named?(Required)

First Last

Legacy Honoree Information:(Required)

Please tell us about your Legacy Honoree (150 words or less.)

Recipient Information

Please note: 1) If there are no applicants that meet the provided parameters, the scholarship will be awarded to a qualifying candidate. 2) Donors may not specify a specific recipient to be awarded their scholarship.

Scholarship parameters:

Please provide any parameters that you would like to direct the awarding of your scholarship? (i.e. I would like this scholarship to be awarded to a teacher from a rural or urban school. / I would like this scholarship to be awarded to someone from the (...) MMEA district.)

Payment

If paying by credit card, please complete the payment information below prior to submitting the information form If paying by check, please submit the information form and submit check payment as outlined on the Legacy Scholarship web page.

Scholarship Donation

Price:

Credit Card

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Cardholder Name

First Last