I have been named a semi-finalist for an AMBUCS Scholars � Scholarships for Therapists Award. In order to proceed with the next phase of the application process, I must submit a completed program acceptance/enrollment certificate to AMBUCS by May 15. Please complete the information below and return to me as soon as possible as proof of acceptance in your program.

Signed ________________________________

(Scholarship Applicant)

1. This is to certify that __________________________________

(Scholarship Applicant)

has been accepted for enrollment in

________________________________________________________________

2. We understand that a scholarship grant is only payable to the school for credit to the

student�s account. Make scholarship checks payable to:

________________________________________ Signed_____________________________ (Title)

(School or University) (Admissions Officer, Registrar, or Program Director)

Instructions for student: After receiving this completed form, write your social security number in the upper right hand corner. Submit it with the other support documents required. This Program Acceptance/Enrollment Certificate should be the top document. The second document required is your personal statement, which should be typed and no more than one page, double-spaced. Third, attach a copy of last year�s IRS 1040 form. Include your parent�s 1040 if you are parent supported (i.e. if your parent or guardian claims you as a dependent on his or her tax forms and helps pay your expenses). Staple the documents together in the upper left-hand corner. Please mail this completed form as well as the other support documents to AMBUCS Scholars, AMBUCS Resource Center, PO Box 5127, High Point, NC 27262. Note: Due to poor reproduction quality, faxes are not accepted.