SCHOLARSHIP AWARD FORM

CAL POLY POMONA
3801 West Temple Avenue
Pomona, CA 91768
SCHOLARSHIP AWARD FORM
List the first recipient here. If you have additional recipients for the same project number, use the "Scholarship
Award Form (con't.)" for the rest of the recipients.
Student'sLast
LastName
Name
Student's
Student's First Name
Bronco Number
Project Number:
Name of College or Organization:
Department Name:
Scholarship Name:
Award Year:
Amount to Award:
Amount to award for the academic year:
(this might be the same as the above amount)
Quarter(s) to Disburse:
Fall
Winter
Spring
Summer
Verified student is currently enrolled at Cal Poly Pomona
Minimum number of units required to maintain this scholarship
Name of Person Preparing Form (please print)
Extension #
Account Authorized Signor (signature)
Date (mm/dd/yy)
Second Authorized Account Signor if applicable (signature)
Date (mm/dd/yy)
This expenditure benefits the educational mission of the CSU and meets the policy requirements of the Education Code Section 89904.6,
Section 9.2 Policy on Expenditure of Funds for CSU Auxiliary Organizations and is in compliance with the University Related Project
Agreement. The item(s) above has/have been received and or service(s) has/have been performed to the satisfaction required and if
applicable, the items and or services are in compliance with the terms and conditions of the grant and/or contract.
SCHOLARSHIP AWARD FORM (con't)
If you have more than one student for the same project number, add the additional students here.
Bronco #
Student Name
Scholarship Name
Amount
2.
3.
4.
5.
6.
7.
8.
9.
10
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
TOTAL for both pages
$ 0.00
Department Approval
Date (mm/dd/yy)
Second Department Approval (if applicable)
Date (mm/dd/yy)
Quarter
(F/W/Sp/Su)