Preble County Safety Council Scholarship Application

PReble County Safety council scholarship Application

Deadline: April 15, 2018

Application INformation

Name: ______Semester and Year of Enrollment ______

Street Address: ______City: ______State: _____

Zip Code: ______Phone: ______Date of Birth: ______

Email Address: ______

Name of High School/College most recently attended______

Date Graduated/Graduating: ______GPA:______

Institution Attending

Name of Institution/College Attending: ______

Address: ______

What is your field of Study/Major/Training Program: ______

Requested Funding Amount: ______Full / Part Time (circle one)

Career Plans/Goal:______

Work experience (Last 2 employers if applicable)

Current Employer Name: ______Job Title: ______

Work Duties: ______

Dates of Work (From/To): ______

Employer Name: ______Job Title: ______

Work Duties: ______

Dates of Work (From/To): ______

Employer Name: ______Job Title: ______

Activities and/or Community SERVICE – List your non-occupational activities (in order of interest to you) in which you have been or are currently involved

Activity: ______

Your most significant contribution: ______

______

Activity: ______

Your most significant contribution: ______

______

Activity: ______

Your most significant contribution: ______

______

Why you would like to receive this scholarship

Give a brief and succinct statement of why you would like to receive this scholarship

Honors – List and describe any special honors/scholarships you have won

List Here (attach a separate page if needed):

Preble County safety council employer information

Employer Name: ______

I am an(Circle One)EmployeeSpouseChild

Name of the Employee: ______

Reference Letters (One letter must be from school faculty member or counselor)

School Faculty Member/Counselor Name: ______

Title: ______Institution: ______

Address: ______

Phone Number: ______Email:______

Reference Name: ______

Title: ______Institution: ______

Address: ______

Phone Number: ______Email:______

Statement of accuracy

I hereby affirm that all the above stated information provided by me is true and correct to the best of my knowledge. I also consent that my picture may be taken and used for purposes deemed necessary to promote the Preble County Council Scholarship Program.

I hereby understand that if chosen as a scholarship winner, I must provide evidence of enrollment/registration at the post-secondary institution of my choice before scholarship funds can be awarded to the institution on your behalf.

I hereby understand that in the event that I do not attend a post-secondary institution the money awarded will be returned to the Preble County Safety Council to be awarded to another scholarship applicant/awardee.

I am a U.S. Citizen: ______(Initial)Date: ______

Signature of scholarship applicant: ______

If under 18 years of age Parent/Guardian Signature: ______

Print Name of Parent: ______Date: ______

Preble County Safety Council Employer Signature: ______

500 Word Essay (may use a separate page)

How you plan to use your education for the betterment of health and safety practice in the workplace or your community

Application submission Checklist

All items must be submitted to the Preble County Safety Council by the deadline. No applications will be considered after that date of April 15th, 2018

______Employer is a Preble County Safety Council Member (PCSC) in good standing

______Awardee/parent is currently employed by a PCSC Member

______Two Letters of Recommendation (School Faculty Member/Counselor and one other) – mailed to the PCSC

______Proof of college acceptance or current student enrollment must be produced if selected as recipient.

______Most recent High School or College Transcripts (must be official and mailed to the PCSC)

______500 word essay (topic on page 4 of this application)

______Completed Preble County Safety Council Application

______Must be present at the Preble County Safety Council Awards Luncheon – May 16th 2018 at 1200 – 1:00pm at the Preble County ESC

Application submission

Send or drop off all application and accompanying materials by April 15th, 2017 to:

Preble County Safety Council

P.O. Box 303

Eaton, OH 45320

Email: