Irs Form 1040 Ez

							               The North Carolina State Firemen’s Association
        FIREFIGHTER GRANT AWARD APPLICATION

                              Please be sure to include:
1.)    A Completed application form
2.)    A letter of recommendation from the Fire Chief (or the fire Chief’s designee) of
       the member department.
3.)    A statement from the applicant discussing the applicant’s goals for his or her life
       and how he or she feels continued education will help achieve those goals.
4.)    A Firefighter’s resume.


Fire Department Name:                         County:

Applicant’s First Name:                       Applicant’s Last Name:

Applicant’s mailing Address:

Phone Number:                         Last 4 Digits of Social Security Number:

Current Marital Status:               Number of Dependents (Including Yourself)

How long have you been a member of the fire service in NC?

Your current rank or position held within the above fire department.

Is the department listed above a current member of The North Carolina State Firemen’s
Association?     Yes       No

Have you been accepted to a college, university, or community college?        Yes       No

If so, please list name, address, and telephone number of college or university:


What program of study are you enrolled in or applying for?

Please describe any unusual circumstances that affect your family’s finance or any
circumstances that you want us to consider for this grant (attach additional sheet if
necessary):


Please list your 2006 Adjusted Gross Income (IRS Form 1040 EZ, line 4; IRS Form
1040A, line 21; IRS Form 1040, line 37):
List any income or benefits received in 2006, which are not included in the above figure:


If no income tax return was filed, please explain why:

Have you received or do you anticipate receiving other scholarships or grants to pay for
your education?      Yes      No
If “yes” please identify the sources (including tuition paid by your fire department):


Please date and sign this form to indicate that the information you have submitted is
accurate and complete to the best of your knowledge.


Applicant’s Signature & Date                         Fire Chief Signature & Date