EmailMe Form - SOROPTIMIST of MIDDLETOWN MIAMI SCHOLARSHIP

PART I - PERSONAL DATA

Name *

Prefix First Middle Last Suffix

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Phone *

### - ### - ####

Banner Number

Email *

Date of Birth *

MM / DD / YYYY

PART II - EDUCATION

A. List high school(s) and college(s) attended. *

	School Name	Dates Attended
1.
2
3.
4.

B. Discuss your educational achievements. Consider your grade point average, your course load, school committees you may have worked on, student government, etc. Only cite examples of recent accomplishments (within the last three years). *

PART III - POTENTIAL FOR ADVANCEMENT

A. Upon completing your course of study, what are your future goals? *

B. What would you consider to be your greatest contribution in time and energy to your school, home, or community in the past three years? Why? *

PART IV - FINANCIAL NEED

A. Are you currently employed? *

Yes

No

If you are currently employed, where do you work and how many hours? *

N/A if you are not currently employed

B. Discuss your financial need below. Describe any special fees, expenses, family obligations, etc. *

PART V. - FILE UPLOAD

Upload your 2 references, and transcripts.
REGARDING REFERENCE LETTERS:
One letter should be from a non-family member.
One letter must be from a Miami University professor. *

upload PDF or Word Doc files only

PART VI. - SIGNATURE

- I certify that all information provided in this application is complete and accurate to the best of my knowledge. I will notify SI Middletown to whom I have submitted this application if there are any changes.

- I certify that this is the only application I have made this year for a Miami University Scholarship, a Virginia Wagner Award or a Live Your Dream Award from this or any other Soroptimist club.

- I understand that my application becomes the property of Soroptimist International of Middletown. The application will be considered confidential, unless the applicant grants Soroptimist written permission to release personal information for the purpose of publicising the Soroptimist Miami University Scholarship. By typing or signing your name below, you adhere to the above requirements.

- I have read and agree to the release of my information to the media, including, but not limited to, newspapers, magazines, or other print or electronic media.

Signature *

Date *

MM / DD / YYYY

Last 4 digits of your Social Security number *