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<HEAD>
<TITLE>SCHOLARSHIP APPLICATION</TITLE>
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<BODY BGCOLOR="#FFFFFF" BACKGROUND="background2.gif">
<P><FONT SIZE="+1" FACE="Helvetica"><FORM ACTION="" METHOD=POST>
<P><FONT SIZE="+2" FACE="Impact" COLOR="#CC3333">APPLICATION<BR>
</FONT><FONT SIZE="-1" FACE="Helvetica" COLOR="#000000"><B>(Please
print)</B></FONT></P>
<P><FONT SIZE="-1" FACE="Helvetica" COLOR="#CC3333"><B>Language
Immersion Experience at the<BR>
Concordia Language Villages, Summer 1999<BR>
<I>Swiss Benevolent Society</I></B></FONT></P>
<P><FONT FACE="Helvetica"><TABLE BORDER=0 WIDTH=550>
<TR>
<TD COLSPAN=4 WIDTH=450 HEIGHT=20 BGCOLOR="#999999">
<P><FONT FACE="Helvetica" COLOR="#000000"><B>PERSONAL
INFORMATION</B></FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT SIZE="-1" FACE="Helvetica">APPLICANT'S NAME:
</FONT></H5>
</TD>
<TD WIDTH=110 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica">last</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica">first</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica">middle</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT SIZE="-1" FACE="Helvetica">DATE OF
BIRTH:</FONT></H5>
</TD>
<TD COLSPAN=2 WIDTH=220 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica">Month / Day /
Year</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-2" FACE="Helvetica">Soc. Sec.
Number</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT SIZE="-1" FACE="Helvetica">PARENTS' NAME:
</FONT></H5>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT SIZE="-1" FACE="Helvetica">HOME
ADDRESS:</FONT></H5>
</TD>
<TD COLSPAN=2 WIDTH=220 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica">Number /
Street</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica">Apt.</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<P></P>
</TD>
<TD COLSPAN=2 WIDTH=220 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-2" FACE="Helvetica">City / State /
Zip</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P><FONT SIZE="-2" FACE="Helvetica">Tel.</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=4 WIDTH=450 HEIGHT=20 BGCOLOR="#999999">
<P><FONT FACE="Helvetica" COLOR="#000000"><B>LANGUAGE
INFORMATION</B></FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=3 WIDTH=340>
<P><FONT SIZE="-1" FACE="Helvetica">Which language(s)
other than English do you speak?</FONT></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=10>
<P><FONT FACE="Helvetica"><B>Language</B></FONT></P>
</TD>
<TD COLSPAN=4 WIDTH=440 HEIGHT=10>
<P><FONT FACE="Helvetica"><B>Skill Level</B></FONT></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica"><INPUT TYPE=checkbox NAME=checkbox414 VALUE=value>beginning
<INPUT TYPE=checkbox NAME=checkbox812 VALUE=value>
intermediate
<INPUT TYPE=checkbox NAME=checkbox480 VALUE=value>
advanced <INPUT TYPE=checkbox NAME=" native" VALUE=value>
native</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica"><INPUT TYPE=checkbox NAME=checkbox414 VALUE=value>beginning
<INPUT TYPE=checkbox NAME=checkbox812 VALUE=value>
intermediate
<INPUT TYPE=checkbox NAME=checkbox480 VALUE=value>
advanced <INPUT TYPE=checkbox NAME=" native" VALUE=value>
native</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=15 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica"><INPUT TYPE=checkbox NAME=checkbox414 VALUE=value>beginning
<INPUT TYPE=checkbox NAME=checkbox812 VALUE=value>
intermediate
<INPUT TYPE=checkbox NAME=checkbox480 VALUE=value>
advanced <INPUT TYPE=checkbox NAME=" native" VALUE=value>
native</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=4 WIDTH=450 HEIGHT=20 BGCOLOR="#999999">
<P><FONT FACE="Helvetica" COLOR="#000000"><B>SCHOOL
INFORMATION</B></FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT SIZE="-1" FACE="Helvetica">NAME OF SCHOOL:
</FONT></H5>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT SIZE="-1" FACE="Helvetica">SCHOOL
ADDRESS:</FONT></H5>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD WIDTH=110>
<P><FONT SIZE="-2" FACE="Helvetica">Number /
Street</FONT></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<P></P>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=6>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=6>
<P><FONT SIZE="-2" FACE="Helvetica">City / State /
Zip</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=6>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=6>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=6>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT SIZE="-1" FACE="Helvetica">Grade you are
currently in:</FONT><FONT SIZE="-2" FACE="Times">
</FONT></H5>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=20 BGCOLOR="#CCCCCC">
<P> <FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=8>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=8>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=8>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=8>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=8>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=20>
<H5><FONT FACE="Helvetica">F</FONT><FONT SIZE="-1" FACE="Helvetica">oreign
languages taught in school: </FONT></H5>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD COLSPAN=3 WIDTH=330>
<P><FONT SIZE="-2" FACE="Helvetica">Are you currently
studying or have you studied any foreign language(s)
before?</FONT></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=110 HEIGHT=10 BGCOLOR="#CCCCCC">
<P><FONT SIZE="-1" FACE="Helvetica"><INPUT TYPE=checkbox NAME=checkbox873 VALUE=value>
no</FONT></P>
</TD>
<TD COLSPAN=2 WIDTH=220 HEIGHT=10 BGCOLOR="#CCCCCC">
<P><FONT SIZE="-1" FACE="Helvetica"><INPUT TYPE=checkbox NAME=checkbox655 VALUE=value>
yes </FONT><FONT SIZE="-2" FACE="Helvetica">(continue
with next question)</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=10>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120 HEIGHT=12>
<P></P>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=12>
<P><FONT SIZE="-2" FACE="Helvetica">List languages you
have studied and for how long:</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=12>
<P></P>
</TD>
</TR>
<TR>
<TD VALIGN=top WIDTH=120 HEIGHT=20>
<P></P>
</TD>
<TD COLSPAN=3 WIDTH=330 HEIGHT=20 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=4 WIDTH=450 HEIGHT=20>
<P><FONT SIZE="-1" FACE="Helvetica">Send completed
application to the address below. Application deadline:
February 15, 1999.</FONT></P>
</TD>
<TD WIDTH=110 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=5 WIDTH=560>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=120>
<P></P>
</TD>
<TD COLSPAN=3 WIDTH=330 BGCOLOR="#CCCCCC">
<P><FONT SIZE="-1" FACE="Helvetica"><B>Swiss Benevolent
Society, Education Committee<BR>
P.O. BOX 2137, Chicago, IL 60690-2137</B></FONT></P>
</TD>
<TD WIDTH=110>
<P></P>
</TD>
</TR>
</TABLE>
</FONT></P>
<P><TABLE BORDER=0 WIDTH=550>
<TR>
<TD COLSPAN=4 HEIGHT=20 BGCOLOR="#999999">
<P><FONT FACE="Helvetica"><B>APPLICATION</B></FONT></P>
</TD>
<TD WIDTH=133 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15>
<P></P>
</TD>
<TD WIDTH=132>
<P></P>
</TD>
<TD>
<P></P>
</TD>
<TD WIDTH=132>
<P></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15 HEIGHT=15>
<P><FONT SIZE="-1" FACE="Helvetica">I </FONT></P>
</TD>
<TD COLSPAN=3 HEIGHT=15 BGCOLOR="#CCCCCC">
<P><FONT COLOR="#CCCCCC">C</FONT></P>
</TD>
<TD WIDTH=133 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15>
<P></P>
</TD>
<TD COLSPAN=2>
<P><FONT SIZE="-2" FACE="Helvetica">Name</FONT></P>
</TD>
<TD WIDTH=132>
<P></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=4>
<P><FONT SIZE="-2" FACE="Helvetica">would like to
apply</FONT><FONT SIZE="-1" FACE="Helvetica">
</FONT><FONT SIZE="-2" FACE="Helvetica">for a scholarship
award from the Swiss Benevolent Society of Chicago for a
two week summer language immersion experience in
<INPUT TYPE=checkbox NAME=checkbox523 VALUE=value> French
or <INPUT TYPE=checkbox NAME=checkbox939 VALUE=value>
German (select one) at the Concordia Language Villages in
Minnesota.</FONT></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15 HEIGHT=20>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=20>
<P></P>
</TD>
<TD HEIGHT=20>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=20>
<P></P>
</TD>
<TD WIDTH=133 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=5>
<P><FONT SIZE="-1" FACE="Helvetica"><B>A completed
application must contain:</B></FONT></P>
</TD>
</TR>
<TR>
<TD WIDTH=15 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=10>
<P></P>
</TD>
<TD HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=10>
<P></P>
</TD>
<TD WIDTH=133 HEIGHT=10>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15>
<P><INPUT TYPE=checkbox NAME=checkbox142 VALUE=value></P>
</TD>
<TD COLSPAN=3>
<P><FONT SIZE="-1" FACE="Helvetica">Filled out
application form.</FONT></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15>
<P><INPUT TYPE=checkbox NAME=checkbox142 VALUE=value></P>
</TD>
<TD COLSPAN=3>
<P><FONT SIZE="-1" FACE="Helvetica">Personal statement
from applicant describing why he/she would like to study
a foreign language /culture. Please include a recent
picture.</FONT></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15>
<P><INPUT TYPE=checkbox NAME=checkbox142 VALUE=value></P>
</TD>
<TD COLSPAN=3>
<P><FONT SIZE="-1" FACE="Helvetica">A letter of support
from applicant's parent(s) indicating their support for
their child's plans to study at the Concordia Language
Villages in Minnesota in the summer 1999.</FONT></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15>
<P><INPUT TYPE=checkbox NAME=checkbox142 VALUE=value></P>
</TD>
<TD COLSPAN=3>
<P><FONT SIZE="-1" FACE="Helvetica">A letter of support
from applicant's teacher or school principle describing
why this student would be an ideal candidate for a two
week stay at the Language Villages in
Minnesota.</FONT></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15>
<P><INPUT TYPE=checkbox NAME=checkbox142 VALUE=value></P>
</TD>
<TD COLSPAN=3>
<P><FONT SIZE="-1" FACE="Helvetica">A check for $ 40 made
out to the <I>Swiss Benevolent Society of Chicago</I>
(for non-members only). Applicants and their families
will receive a one-year membership in the Swiss
Benevolent Society of Chicago.</FONT></P>
</TD>
<TD WIDTH=133>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15 HEIGHT=20>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=20>
<P></P>
</TD>
<TD HEIGHT=20>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=20>
<P></P>
</TD>
<TD WIDTH=133 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD COLSPAN=4 HEIGHT=20 BGCOLOR="#999999">
<P><FONT FACE="Helvetica"><B>PERSONAL
STATEMENT</B></FONT></P>
</TD>
<TD WIDTH=133 HEIGHT=20>
<P></P>
</TD>
</TR>
<TR>
<TD WIDTH=15 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=15>
<P></P>
</TD>
<TD HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=132 HEIGHT=15>
<P></P>
</TD>
<TD WIDTH=133 HEIGHT=15>
<P></P>
</TD>
</TR>
<TR>
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