ALEX MEMORIAL SCHOLARSHIP FUND APPLICATION - 2010

SECTION A: APPLICANT

Name: First__________________________ MI_______ Last ______________________________

Home Address: Street _____________________City____________ State___ Zip Code________

Current Mailing Address_____________________________________________________________

Telephone: Daytime (_____) ____________________ Evening (_____)_____________________

Cell phone: _________________________________________

E-Mail Address ____________________________________________

Mother's or Father’s Name (if you are not a PWN Member) __________________________________

SECTION B: EMPLOYMENT

Current Employer: Name/Address___________________________________________________

Job Title___________________________ Hire Date____________ Full Time___ or Part Time___

List three previous employers (starting with the most recent)
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Current Earnings:
Up to $15,000 ( ) $15,001 to $30,000 ( ) $30,001 to $60,000 ( ) Above $60,000 ( )

Do you plan to continue to be employed while attending school? Yes_________ No_________

Do you have sources of income other than your employment? Parent(s)__ Spouse__ Other__

SECTION C: EDUCATION

High School ________________________________________________________

College (if any previously attended)_______________________________________

Educational institution you are attending or plan to attend________________________________

Advisor (if any)__________________________________ Telephone ( ) ____________________

How many credit hours are you taking/or do you plan to take? ___________________________

Degree or Certificate you are seeking_______________________ Major____________________

When do you expect to complete your degree or certification? ___________________________

SECTION D: EXPENSES

Estimate the following expenses for each semester. (Round off to the nearest $.)

Item ..... 1st Semester ..... 2nd Semester

Tuition :

$ ____________

$ ____________
Books :

$ ____________

$ ____________
TOTAL:

$ ____________

$ ____________

SECTION E: REVIEW AND CONFIRMATION

Please verify/check the following items and sign before submitting your application.

( ) I have completed Sections A through D as required.

( ) I have attached a "Personal Statement".

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.

Signature______________________________________________ Date ________________

FOR PWN USE ONLY

Date Application Received_____________

Date Applicant Notified of Interview_____________

Date Applicant Notified of Decision_____________

Please print out the form, complete, attach "Personal Statement" and mail to: P.O. Box 6538 Kaneohe, Hawaii 96744. Must be postmarked no later than August 1, 2010. Applications may be turned in at luncheon registration at the July 22, 2010 luncheon.

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contact@pwnhawaii.org
P.O. Box 6538 Kaneohe, Hawaii 96744