2008 DPSOA SCHOLARSHIP APPLICATION
CHECK ONE
  INITIAL SCHOLARSHIP (If you have not received a previous DPSOA Scholarship)
CONTINUING (If you have received a previous DPSOA Scholarship)
Name:

Address:

City:

State:

Zip:

Phone:
E-mail:  
Home Phone:

Secondary Phone:
Birth Date:

Birth Place City:

 Birth Place State:

SS#:
Father's Full Name  

Is Parent a DPSOA member?   No  Yes
Mother's Full Name  

Is Parent  a DPSOA member?  No  Yes
Father's Occupation:  

Business Phone:   

  
Mother's Occupation:  

Business Phone:   

  
Father's Annual Income:  

 

Mother's Annual Income:

 
Number of Siblings:  

Number of Siblings in College:    

         

School Plan To Attend:

Applied? 

No Yes

Accepted?

No Yes

  Entrance Exam Taken?

No

     Yes
Describe Exam and Score:
Field of Study and Brief Description of Career Plans:
NOTE, CIRCUMSTANCES, PREVENTING YOU FROM ATTENDING COLLEGE IF YOU DO NOT RECEIVE  FINANCIAL ASSISTANCE"
 
High School Attended:

City:

  State:  
Work Experience
Place of Employment:
Type Of Job:
Supervisor's Name:
Have You Applied For Any Other Scholarship?  

No

 Yes
If Yes, Describe:  
Have You Received a Scholarship?

No

 Yes
If Yes, Describe:

Check to be Made Payable to:

 

 MUST BE A COLLEGE, UNIVERSITY, OR TRADE SCHOOL
Signature:  _______________________________________________ Date:  

ALL PERTINENT ITEMS MUST BE ANSWERED

ANY OMISSION OF NECESSARY INFORMATION MAY PREVENT CONSIDERATION OF APPLICATION
FOR COMMITTEE USE: 

 Photograph____  Transcript____  Narrative____  Instruction Sheet_____   Other_______
  

              APPROVED _______________________               NOT APPROVED_________________________
   
   

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If you have any questions call
Patti Benson at the DPSOA Office at 1-800-933-7762
or e-mail :