manasota chapter of florida surveying and mapping society - FSMS

__________________CHAPTER OF FLORIDA SURVEYING AND MAPPING
SOCIETY
SCHOLARSHIP APPLICATION
Section I
Personal Information
Applicant Name:__________________________________________________________________________________
Last First Middle
Mailing Address:__________________________________________________________________________________
City:____________________________________ State:______________________ Zip Code:____________________
Home Phone:___________________________________ Work Phone:______________________________________
Fax:_________________________________ E-Mail Address:_____________________________________________
Are you a U.S. Citizen:______Yes ______No If no, explain the basis of your legal residence in the U.S.:_________
________________________________________________________________________________________________
______________________________________________________ Visa #___________________________________
Military Status: Class_____________ Veteran:_________ Yes __________No
Marital Status:____________________ Number of dependents, including self:________________________________
Section II
Financial Information for this academic year
(Married students must include total family income)
A. Estimated Costs B. Financial Resources
Tuition and Fees $_____________ Savings $____________
Room & Board $______________ Scholarships $____________
Books $______________ Parent/Guardian $____________
Supplies $______________ Vacation Income $____________
Transportation $______________ Part-time Income $_____________
Clothing $______________ Income of Spouse $_____________
Medical $______________ GI Benefits $_____________
Personal $______________ Education Loans $_____________
Other $______________ Other $_____________
Total $______________ Total $_____________
Amount requested from the________________ Chapter of Florida Surveying and Mapping Society Scholarship Fund:
$___________________.
Present/Previous Educational Scholarships or Loans: (List name of fund, account, current balance and for what school
period) _________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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Have you ever defaulted on a loan If yes, explain: ______________________________________________________
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Section III
Education and Employment History
Current Employer:________________________________________________________________________________
Address:________________________________________________________________________________________
City:_________________________________ State:__________________________ Zip Code:__________________
Date Employed:____________________ Position:______________________________________________________
May we contact for reference ____Yes ____No If yes, Phone & Contact Name:_____________________________
Previous Employer:________________________________________________________________________________
Address:________________________________________________________________________________________
City:_________________________________ State:__________________________ Zip Code:__________________
Date Employed:____________________ Position:______________________________________________________
Phone:_______________________ Contact Name:______________________________________________________
Previous Employer:________________________________________________________________________________
Address:________________________________________________________________________________________
City:_________________________________ State:__________________________ Zip Code:__________________
Date Employed:____________________ Position:______________________________________________________
Phone:_______________________ Contact Name:______________________________________________________
High School Name:________________________________________________________________________________
Address:________________________________________________________________________________________
Phone:_________________________ Teacher/Advisor/Counselor:_________________________________________
Curriculum:_____________________ Scholastic Standing:___________________ G.P.A.:_____________________
Describe in detail your existing Surveying experience:____________________________________________________
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Section IV
Educational Institution
Name of Educational Institution:_____________________________________________________________________
Address:______________________________________________________ __________________________________
City:___________________________________ State:_______________________ Zip Code:___________________
Program/Department:______________________________________________________________________________
Major/Field of Study:______________________________________________________________________________
Type of Degree Sought:____________________________________________________________________________
Academic Class: Freshman________ Sophomore_________ Junior_________ Graduate_________
Quarter/Semester/Year Completed:______________________ Expected Graduation Date :_________________
Full Time Student:_______Yes ______No Expected to Complete Program: __________Yes _________No
Current Grade Point Average (Based on 4.0 = A):______________ As of what date:________________________ ___
Have you ever been convicted of a crime: ____________ . If so, please provide details below in the comment section.
This does not include traffic infractions, except DUIs.
References/Mentor:
Name:__________________________________________________ Phone:_________________________________
Address:__________ ______________________________________________________________________________
Name:__________________________________________________ Phone:_________________________________
Address:________________________________________________________________________________________
Name:__________________________________________________ Phone:_________________________________
Address:________________________________________________________________________________________
Do you plan to take the PSM license exam ___________Yes _________No If yes, when_____________________
Do you plan to work in the ___________________County area ________Yes _________No
Or the State of Florida ________Yes __________No
Are you currently a member of the Florida Surveying and Mapping Society (Student or Assoc.) _____Yes ______No
What are your educational and career goals Are there factors which make you particularly deserving of support (Use
reverse side if necessary)___________________________________________________________________________
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Comments:______________________________________________________________________________________
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A scholarship in the amount of $_____________ is recommended for this applicant.
Date:______________________
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Signature
_______________________________________________
Title
Approved:_______________
Declined:________________