Application Must Be Filled out Completely and Legibly to Be Considered Eligible for the Award

MAC-IECA Scholarship Application Form (Post Marked no later than January 8, 2018)

Application must be filled out completely and legibly to be considered eligible for the award.

Student Information:

Date:

Name:

School/Local Address:

City/State/Zip:

School/Local Phone: ( )

Email Address:

Permanent/Home Address:

City/State/Zip:

Home/Permanent Phone: ( )

I am currently registered as a full time student at:

College/University

Address:

City/State/Zip:

I am enrolled as a full time student in the following department:

Department:

Declared Curriculum/Major:

Expected Date of Graduation:

Overall GPA: Major GPA:

Please list recent awards, honors, and related work experience:

Please list a reference (non-relative):

Name:

Address:

City/State/Zip:

Relationship to Reference:

Daytime Phone Number:

Evening Phone Number:

Number of Years Known to Reference:

(continued)

Please read and sign the following:

I understand that the scholarship selection will be based on the content of the application, the letter of reference and the submitted essay. Scholarship awardees will be invited to attend the Annual MAC-IECA Conference and possibly make a brief presentation during the award ceremonies.

I certify that all the information contained in this application is true and the submitted essay is original and solely my own creation.

Signature of Applicant:

Date:

Printed Name of Applicant: