Ephraim G. Sless Memorial Fund
Scholarship Fund Application
Chairman: Frater Andrea Pallotta
apallot@gmail.com
3512 Burrwood Drive
Richfield, OH 44286
|
DEADLINE DATE: MAY
30, 2010
Scholarship App in DOC format
INSTRUCTIONS: Please type or print plainly and return by
deadline date. Consideration of late applications is not guaranteed by the committee.
INCLUDE
AN UP-TO-DATE CERTIFIED TRANSCRIPT OF YOUR GRADES.
Mail applications to the Memorial
Fund Chairman . Mark the outside of the envelope "Scholarship Application" so
that it may be turned over to the committee unopened.
Selection of recipients of
scholarships is solely within the discretion of the Alpha Zeta Omega Pharmaceutical
Fraternity, and the Ephraim G. Sless Memorial Fund Scholarship Selection Committee.
ELIGIBILITY: In order to be eligible to receive
scholarship assistance, the applicant and his / her chapter must be in good standing with
the Supreme Chapter of the Alpha Zeta Omega Pharmaceutical Fraternity The applicant shall
have the responsibility of confirming the status for applicant and his / her chapter.
Name:______________________________________________ Date
of Birth:___________________________
Permanent
Address:__________________________________________________________________________
Marital Status:_________________________
Name of Pharmacy School Applicant
Attends:_____________________________________________________
__________________________________________________________________________________________
Name and Address of Parent or
Guardian:________________________________________________________
Phone Number Home:(_____)______-____________ Phone Number
College:(_____)______-______________
Father's Occupation:________________________ Mother's
Occupation:________________________________
Number in Family Household:_________________
Number in Family in Elementary and / or High
School:___________________ In College __________________
Number of Brothers or Sisters Living in Household and
Working______________________________________
Parent's gross income (to show financial need: indicate
amounts, if any, from Social Security disability or other income)
__________________________________________________________________________________________
INCOME: |
EXPENSES: |
| Cash on hand or savings:
_____________ |
Tuition or Fees:
____________ |
| Assistance from family:
_____________ |
Room and board:
____________ |
| Books:
_____________ |
Other (specify):
_____________ |
| Student's anticipated earnings:
_____________ |
|
| Other (specified):
______________ |
|
TOTAL INCOME ________________
TOTAL EXPENSES: _____________
| Do you own your own a car?
Yes____ No_______ |
Do you commute to school? Yes____ No_______ |
| Do you live in a dormitory? |
Yes____ No_______ |
| Apartment? |
Yes____ No_______ |
| Home? |
Yes____ No_______ |
| Other? |
Yes____ No_______ |
Are you currently holding a scholarship or have you
applied for a scholarship? Yes____ No_______
Please indicate those currently
held and number of years:
NAME
OF SCHOLARSHIP: |
AMOUNT
OF SCHOLARSHIP: |
| ___________________________________________ |
___________________________________________ |
| ___________________________________________ |
___________________________________________ |
| ___________________________________________ |
___________________________________________ |
| ___________________________________________ |
___________________________________________ |
List all honors and accomplishments which indicate good
scholarship and list all school activities and clubs. Specify major off ices held in each
what hew you held In your chapter and when?
PRE-PHARMACY:____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
PHARMACY:________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
List all church and community activities,
including major offices and responsibilities:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_______________
Additional information you wish the Scholarship
Committee to know:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________
I hereby certify that the above information is
true and correct and authorize the Alpha Zeta Omega pharmaceutical Fraternity to
investigate any information provided in this application and to contact the appropriate
persons and entities named.. I further agree to provide additional confirmation of
information contained in this application upon request.
Signature:_______________________________________Date:__________________________
