Accident Survivor Scholarship Application Name* First Last Date of Birth* MM slash DD slash YYYY Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Where are/will you be attending school?* What is your current status at that school?Enrolled StudentAccepted Not Yet EnrolledUsing fewer than 500 words, tell us how you overcame a serious injury suffered as a result of a car accident, medical error, or other incident caused by someone’s carelessness.*I understand that my name and photograph will be used to publicly announce the awarding of the Briskman Briskman & Greenberg Accident Survivor Scholarship if I am selected. I also understand that payment will be made directly to my school on my behalf.*NoYes Save and Continue Later Δ The award will be paid directly to the winning applicants school on their behalf. Please consult with a tax professional regarding IRS reporting requirements, Topic 421 – Scholarships, Fellowship Grants and Other Grants.