SOUTHWEST SECTION, INC.OFFICE USE ONLY

MEMORIAL SCHOLARSHIP FUNDDate rec'd:

315 Bourque StreetTranscript enclosed:yes no

Kaplan, LA 70548Photo enclosed:yes no

Membership verifiedyes no

APPLICATION

MUST BE POSTMARKED BY JUNE 25.

MUST BE ACCOMPANIED BY SCHOOL TRANSCRIPT.

1)Applicant's Name:______

Address:______Phone:______

City:______State:______Zip:______

2)Is parent or legal guardian an active member of Southwest Section, American Water Works Association?

yes no

3)Name and address of qualifying parent: ______

______

Other parent's name and address: ______

______

4)How many members of your family are living at home?______

5)Applicant's age:______Date and Place of Birth:______

6)What college or university do you plan to attend?______

7)EDUCATIONAL DATA:

  1. Name and location of high school attended:______

______Year Graduated______

  1. Any other pre-college studies, such as trade schools, commercial college, seminars, workshops, etc.

(type and duration):

______

______

______

  1. Special or principal high school studies, if any______

______

  1. Scholastic honors______

______

______

  1. Class officer positions held:______

______

  1. Club and organizational memberships and offices held:______

______

______

______

  1. Participation in athletics, music, drama, speech:______

______

______

______

  1. Any other school extracurricular activities:______

______

  1. Non-school-related activities:

Church and religious______

______

______

______

Youth Organizations______

______

______

______

Other (hobbies, leisure pursuits)______

______

______

______

  1. Employment after school or vacations (employer and type of work):______

______

______

______

  1. Preparatory school - name:______

Location:______

Years attended: Did you graduate? yes  no 

  1. Colleges attended:

(1)Name:______

Location:______

Years attended:______

(2)Name:______

Location:______

Years attended:______

Major subjects:______

Minor subjects:______

Scholastic honors:______

______

______

______

Non-academic interests followed, club memberships, etc: ______

______

______

8)Please set forth in brief essay form what you hope to gain from a college education and what are your general goals in life.

______

______

______

______

9)ESTABLISHING ELIGIBILITY OF PARENT OR LEGAL GUARDIAN:

  1. Qualifying parent's name ______
  2. Employed by what utility or firm? ______
  3. Parent's title ______
  4. Employment address ______
  5. Parent's AWWA Membership______Member since ______

(AWWA Number) (Month and Year)

  1. Number of years in water/wastewater field______
  2. Competency certificates held:______

______

______

  1. Special awards or recognition:______

______

______

  1. Offices held in AWWA Section:______

______

______

APPLICANT AFFIRMATION. If selected for a scholarship award, I agree to use the cash received toattend a college or university. If my award cannot be used forth at purpose, I will notify theScholarship Fund immediately. If I drop out of college during the first semester of the award or between the first and second semester, I agree to notify the Scholarship Fund immediately.

Signature of applicant:______

Date:______State:______

Please return to:

Southwest Section Memorial Scholarship Fund

c/o Don Broussard, P.E.

315 Bourque Street

Kaplan, LA 70548

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