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					Susan Jensen - Gorham Savings Bank Sch App.doc                                                                                                                        Page 1

               The Gorham Savings Bank Scholarship
                     Application Form 2004-05
                                                                                       Last Name                                    First Name                M.I.

       The University of Maine System is pleased to announce The Gorham
       Savings Bank Scholarship for 2004-05. This scholarship fund is made             Address:
       possible by a generous gift from Gorham Savings Bank. One $500
       scholarship is available.
                                                                                       City _________________________Zip Code _________ Tel #: ______________
       Eligibility Requirements:
       ? Undergraduate University of Maine System students enrolled at least ½         Campus of Enrollment                         Grade Level
           time in a degree program who are children, stepchildren, or grandchildren
           of current employees of Gorham Savings Bank.                                Major                      GPA               Awards

       To apply:
       1. Complete the application form                                                Personal statement:
       2. Have the application certified by a Gorham Savings Bank Official.
                                                                                       Name of Gorham Savings Bank Employee and relationship to you:

       The application deadline is October 29, 2004. Please send your application
       to:                                                                             CERTIFICATION

                                                                                       This is to certify that the above is a current Gorham Savings Bank employee.
                                Scholarship Committee
                              Office of Student Financial Aid
                                   University of Maine                                 (Gorham Savings Bank Official signature)
                                    5781 Wingate Hall
                                Orono, ME 04469-5781                                   By signing this form I agree that the information on this form may be
                                  Fax: (207) 581-3261                                  used by The University of Maine System and The University of
                                                                                       Maine Foundation to communicate with scholarship donors and for
                                                                                       publicity and press releases.

                            For more information please contact:
                                                                                       ______________________________________ ______________
             Gianna F. Marrs ( or Kathy Boutilier
                    (, University of Maine              Applicant Signature                                           Date
                           Telephone: (207) 581-1324 or 5 81-1329

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