SHARING

THE

Scholarship Application

Full Name *

Phone *

Email *

Group You Attend (day, time, and location) *

Total Gross Monthly Household Income *

Number of family members dependent on this income *

Please provide relief from...

Factors or circumstances that make it difficult to pay my Pure Life Alliance group fee *

I would like relief from the Pure Life Alliance Fee for...

By signing and submitting this form I understand the following... *

This Scholarship is not guaranteed. Upon submittal the application will be reviewed by our scholarship team. They will respond within one week.

If you should receive a scholarship it will be for up to a three month period. It is the responsibility of the undersigned to resubmit the application if more time is needed.

Signature