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PLEASE PRINT
Part I
Name: (last) ___________________________ (first) ____________________________ (MI) ______________
Address: _________________________________________________________________________________
City: ___________________________________________ State: ________________ Zip: ________________
Phone: ____________________________________ Cell: __________________________________________
Fax: ___________________ Email: ____________________________________________________________
Name/s of Parent(s) or Guardian(s):____________________________________________________________
Address/City/State/Zip: ______________________________________________________________________
Mother's Occupation: ______________________________ Father's Occupation: ________________________
Part II
University/College Name: ____________________________________________________________________
Address: __________________________________________________________________________________
City: _________________________________________________ State: ________________ Zip: __________
Major Course/Program Applied For: ____________________________________________________________
Any other programs:_________________________________________________________________________
Degree Sought: _____________________________________________________________________________
Have you been accepted? Yes: ____ or No: ____ (If yes attach a copy of acceptance letter.)
Full Time: ______ Part Time: ____ (If Part Time, please explain in your letter of introduction)
Intended Semester of Entrance: Fall: ___ Spring: ___ Summer: ___ Year: ______
Amount of Enrollment: ____________________
Part III
Name and Address of High School: _____________________________________________________________
Dates attended: __________________________________ GPA: ____________ SAT Score: _______________
Please attach a copy of official high school transcript and test scores.
_____________________________________________________________________ __________________
Signature of Counselor: Date
_____________________________________________________________________
Printed Name of Counselor
Part IV
Church, Local Association Service: _____________________________________________________________
_________________________________________________________________________________________
School/Community Activities: _________________________________________________________________
_________________________________________________________________________________________
Any Internships or Employment in related aviculture field: __________________________________________
_________________________________________________________________________________________
Honors/Special Recognition: __________________________________________________________________
_________________________________________________________________________________________
List names and address of three (3) references. These persons should be non-relatives. (Minister, teacher, other adult leaders).
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
The applicant must include three letters of recommendation from the references in their completed packets. Please have sent to Scholarship Committee.
All applicants must write an introductory letter indicating personal interests, reason for applying for a scholarship and future education plans. Please attach to scholarship form.
Read carefully before signing.
1. I understand any false statements on this application shall be sufficient cause for rejection.
2. My academic transcript may be released to the Wayne P. Hawkins Memorial Scholarship Committee. All information will be kept confidential.
3. I understand that if I am awarded a scholarship/grant by the Carolinas Virginia Pheasant and Waterfowl Society, it has been awarded to me on the basis of the information provided in this application. If my situation changes and I do not start the course or program, it is my understanding that I will be requested to return the full amount of the award.
________________________________________________________________________________________________ Signature of Applicant __________________ Date ________________________________________________________________________________________________ Signature of Parent(s) or
Guardian(s) __________________ Date
Carolinas Virginia Pheasant and Waterfowl Society
Wayne P. Hawkins Memorial Scholarship Program
Reminders and Checklist for Applicant
Checklist
A completed application consists of:
____ Three (3) letters of recommendation, non relative (minister, teacher, other adult leaders)
____ A letter of introduction about your self (photos if you wish)
____ Financial statement of previous year applied. (Copy of W-2 form).
____ Typed original essay 250 words minimum or one-page double spaced and a maximum of 500 words.
____ Official transcript and test scores from guidance counselor
____ Materials returned in a large envelope
Eligibility Requirements
1. Applicant must be a high school senior or a registered university/college student
2. Applicant must be able to document financial need.
3. Applicant must possess a cumulative average of "B" or better and/or a minimum 3.0 cumulative on the uniform grading scale.
4. Applicant must be majoring in a field of Aviculture.
Responsibility of Applicant
1. Adhere to deadlines
2. Submit all information to the Scholarship Committee by .
3. Complete application in its entirety.
4. Check application for correctness or information before submitting to the committee.
5. Confirm that the three letters of recommendation have been sent and received.
6. Submit a typed, original essay. The essay must be a minimum of 250 words or one page double spaced, and a maximum of 500 words from a theme to be chosen by the Scholarship Committee.
7. Attach to the application a current high school transcript with guidance counselor's signature.
8. Proof of income (copy of W-2 form)
9. If necessary, be available for a phone interview.
Responsibility of Scholarship Recipient
1. A required article for print in the Society Magazine to update status of education and/or aviculture experiences.
2. Inform the Scholarship Committee Chairperson of the selected university or college and the date the scholarship check should be disbursed to the institution at least forty-five (45) days prior to due date.
3. Send written notification to the Scholarship Committee of changes in plans, status or location at least sixty (60) days prior to any disbursement of funds.
4. Send to Scholarship Committee the date of Awards Days Ceremony at the local high school. Or if you are an established university/college student date of any Awards Ceremony.
Mail Applications To:
Name, Address, City, State, Zip
Al and Pat Novosad
Jimmy Spady
Dr. Mickey Hall
Nick and Carolyn Surian
Dean and Mint Schlief
ET and Jan Trader
Don and Ann Butler
Katherine Randall
Dr. Dennis Martin
Thomas and Lynn Gaskin
June Jarvis
Chris Lawrence Jr. and Family
Erna Liebrandt
John and Carol Hansell
Office of Hearings and Appeals Sunshine Club
Mr. and Mrs. Thomas Baston
Mr. and Mrs. RW Taylor
Mr. and Mrs. KR Francingues
Mrs. James Wedworth
Geradine Hammons
Shelly Jarvis
Total of Memorial donations as of June 30 2005 $1200.00