Dorothy L. Johnson Memorial Scholarship

Department of Recreation Administration - Eastern Illinois University

Name Name First Last
Date Date / MM / DD YYYY
Campus Address Campus Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Campus Phone Campus Phone - ### - ### ####
Other (Cell) Phone Other (Cell) Phone - ### - ### ####
Email
Permanent Address Permanent Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Permanent Phone Permanent Phone - ### - ### ####
Cumulative GPA
Major
Status
Letter of Application (DOC or PDF)