SAMI online application

STOP! Before completing this online application, please review all sections of the offical application form.

In addition to the information here, a letter of recommendation must also be submitted by email to: secretary@samisong.com or mailed to the The Arts Federation at the address listed on the official application. The MP3 of the original song may be emailed to scholarship@samisong.com. Please contact Cheryl Fletcher, SAMI Secretary, with any questions at secretary@samisong.com.
Shirley Martin Scholarship for Young Songwriters Application

Songwriters Association of Mid-North Indiana
Full Name*

First NameMiddle InitialLast Name
Age:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you been a resident of Indiana?*
County of residence?*
Last school and grade attended?
Phone 1:

Area CodePhone Number
Phone 2:

Area CodePhone Number
Birth Date:*

MonthDayYear
E-mail Address:*
How did you learn of the scholarship?
How would receiving the scholarship assist you in pursuing your passion for songwriting?*
Reminder: Submit MP3 of original song via email to scholarship@samisong.com.
Song title:*
Lyrics:*
If applicant is less than 18 years of age, then a legal guardian must provide their initials and email below as a signature of approval:
Guardian Initials:
Guardian E-mail:
Relationship to applicant:
The applicant must complete all of the elements of the form in conjunction with fulfilling the requirements defined in SECTION 3 of the scholarship charter. By signing below the applicant testifies that all of the information provided is factual to the best of his or her knowledge. The applicant affirms that their submitted songs are original and that the application is complete. The applicant realizes that failure to provide a complete and accurate application would result in disqualification. SAMI reserves the right to disqualify any applicant who violates the rules and regulations as described in the scholarship charter.
Applicant Initials:*
Should be Empty:

Shirley Martin Scholarship for Young Songwriters Application