HOSTNETWORKAPPLICATION–HOSTNETWORK
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HOSTNETWORKNAME
NameofHostNetwork
A
FirstName
B
HOSTNETWORKGROUPLEADER
LastName
DateofBirth(MM/DD/YYY)
HOSTNETWORKMEMBERS
*AHostNetworkmustconsistoffive(5)members.
LastName
DateofBirth(MM/DD/YYY)
1
L
LastName
LastName
DateofBirth(MM/DD/YYY)
DateofBirth(MM/DD/YYY)
LastName
5
Apt./Unit#
BusinessofCellPhone
DateofBirth(MM/DD/YYY)
Address(Street&Number)
HomeTelephone
NA-HN(02-2015)
City
ZipCode
State
ZipCode
State
ZipCode
State
ZipCode
Emailaddress
FirstName
MiddleNames
RelationshiptoHostNetworkGroupLeader
Apt./Unit#
BusinessofCellPhone
City
Emailaddress
FirstName
MiddleNames
RelationshiptoHostNetworkGroupLeader
Apt./Unit#
BusinessofCellPhone
City
Emailaddress
State
MiddleNames
RelationshiptoHostNetworkGroupLeader
Address(Street&Number)
HomeTelephone
ZipCode
State
Emailaddress
FirstName
Address(Street&Number)
LastName
City
HomeTelephone
4
BusinessofCellPhone
Address(Street&Number)
HomeTelephone
3
Apt./Unit#
DateofBirth(MM/DD/YYY)
2
MiddleNames
RelationshiptoHostNetworkGroupLeader
Address(Street&Number)
HomeTelephone
FirstName
FirstName
MiddleNames
RelationshiptoHostNetworkGroupLeader
Apt./Unit#
BusinessofCellPhone
City
Emailaddress
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Wedeclarethattheinformationprovidedistothebestofourknowledgetrue,completeandaccurate.
Wearenotindefaultofanyotherscholarshipundertakings.
Wearenotindefaultofanyloans.
WehavemadeorwillmakeadequatearrangementsintheexpectedscholarshiprequirementsoftherefugeesmatchedtoourHostNetwork.
Tothebestofourability,wewillknotknowinglyordeliberatelyallowanyindividualtoparticipateinthegroup’sscholarshipactivitieswhomaybeconsidereda
threattothesafetyandsecurityoftherefugees.
Weunderstandthatanyfalsestatementsorconcealmentofanymaterialfactmayresultin,butisnotlimitedto,thefollowingconsequences:
•
Refusaltoapprovethisorfutureapplications;
•
Revocationofanyexistingscholarshipapplication;
•
Prosecutionorotherenforcementaction.
Weunderstandthatthescholarshipapplicationconstitutesafinancialobligationthatcouldresultincollectionaction,shouldtherebeabreachofthatobligation.
SIGNATURESFORHOSTNETWORKMEMBERS:
Member1name(printname)
Signature
Date(MM/DD/YYYY)
Member2name(printname)
Signature
Date(MM/DD/YYYY)
Member3name(printname)
Signature
Date(MM/DD/YYYY)
Member4name(printname)
Signature
Date(MM/DD/YYYY)
Member5name(printname)
Signature
Date(MM/DD/YYYY)
CONFIDENTIALITYNOTICE:TheinformationyouprovidedonthisformiscollectedbytheUtahValleyRefugeeActionNetworkandwillbeusedtomaintainarecord
ofapplicationandscholarshipundertakingsbylocalHostNetworksandwillberetainedbythisOrganizationinstrictconfidence.Detailsonthesemattersare
availableuponrequesttotheUtahValleyRefugeeActionNetwork.AllCONTENTandATTACHMENTS,includingideasand/orcontactsofthisemailare
CONFIDENTIALandCOPYRIGHTED©RefugeeActionNetwork.
NA-HN(02-2015)