Art Scholarship Application Form

	Make the Difference 2010 AITM Art Scholarship Donation Form PRINT, Complete and MAIL your Form and Donation to: Art In The Mountains PO Box 311, Mehama, OR 97384

Name:	_________________________________	I would like to establish a scholarship in this name:
Address:	_________________________________	__________________________________
City, State, Zip:	_________________________________	Is this is a memorial scholarship?
Phone:	_________________________________	__________________________________
Cell:	_________________________________	Will this be an annual donation/scholarhip?
E-Mail:	_________________________________	__________________________________

I would like to donate $_________________ to be given to the recipient(s) of this years Scholarship for art supplies .

I would like to donate $________ toward this years scholarship(s) to be given to a second or third applicant.
($595 will create an additional scholarship).
I would like to donate $ _________ toward either art supplies or toward a scholarship. AITM to use in most needed
scholarship fund.

I would like to donate $ _________ for the scholarship above that I would like to establish.

AITM will create a list on the website to recognize all donors. If you wish to remain anonymous please check here ____

If you are establishing a scholarship and would like to provide criteria other than the criteria at AITM, please
provide the criteria below and we will publish the new scholarship to our website immediately:

Scholarship Name:___________________________________________

1.
___________________________________________________________________________________________

___________________________________________________________________________________________
2.
___________________________________________________________________________________________

___________________________________________________________________________________________
3.
___________________________________________________________________________________________

___________________________________________________________________________________________
4.
___________________________________________________________________________________________

___________________________________________________________________________________________
(Attach additional sheets if necessary)

If the scholarship is a memorial scholarship please provide us with a write-up/bio of
the individual for the website so we can honor the their memory.

Thank you for your donation and your desire to help those around you aspire to become better artists.
Your monetary contribution to the art world will make a difference in someone's life.