ALEX MEMORIAL SCHOLARSHIP FUND APPLICATION – 2012
| SECTION A: APPLICANT | |
| Name: First__________________________ MI_______ Last ______________________________ | |
| Home Address: Street _____________________City____________ State___ Zip Code________ | |
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Current Mailing Address_____________________________________________________________ |
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Telephone: Daytime (_____) ____________________ Evening (_____)_____________________ Cell phone: _________________________________________ |
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E-Mail Address ____________________________________________ |
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Mother’s or Father’s Name (if you are not a PWN Member) __________________________________ |
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SECTION B: EMPLOYMENT |
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Current Employer: Name/Address___________________________________________________ |
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Job Title___________________________ Hire Date____________ Full Time___ or Part Time___ |
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List three previous employers (starting with the most recent) _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ |
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Current Earnings: Up to $15,000 ( ) $15,001 to $30,000 ( ) $30,001 to $60,000 ( ) Above $60,000 ( ) |
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Do you plan to continue to be employed while attending school? Yes_________ No_________ |
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Do you have sources of income other than your employment? Parent(s)__ Spouse__ Other__ |
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SECTION C: EDUCATION |
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High School ________________________________________________________ |
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College (if any previously attended)_______________________________________ |
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Educational institution you are attending or plan to attend________________________________ |
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Advisor (if any)__________________________________ Telephone ( ) ____________________ |
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How many credit hours are you taking/or do you plan to take? ___________________________ |
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Degree or Certificate you are seeking_______________________ Major____________________ |
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When do you expect to complete your degree or certification? ___________________________ |
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SECTION D: EXPENSES |
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Estimate the following expenses for each semester. (Round off to the nearest $.) |
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Item …..1st Semester ….. 2nd Semester |
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Tuition : $ ____________ $ ____________ Books :$ ____________ $ ____________ TOTAL:$ ____________ $ ____________ |
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SECTION E: REVIEW AND CONFIRMATION |
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Please verify/check the following items and sign before submitting your application. |
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( ) I have completed Sections A through D as required. |
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( ) I have attached a “Personal Statement”. |
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I certify that the information I have provided is accurate and complete, and authorize the PWN Scholarship Committee to verify any facts it deems necessary. I understand any false or misleading statements will result in my disqualification. |
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Signature______________________________________________ Date ________________ |
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FOR PWN USE ONLY |
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Date Application Received_____________ |
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Date Applicant Notified of Interview_____________ |
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Date Applicant Notified of Decision_____________ |
