Service Award for Post High School Study
Code No. _________
APPLICATION - Page 1 (Please type or print legibly)
1. Name __________________________________________________________________
Last First M.I. 2. Date of Birth ___________________________________________________
3. Address ________________________________________________________________
No. and Street Apt.
___________________________________________________________________________
City/Town State Zip
4. Telephone _________________________________
5. Current High School ____________________________________________________
6. Other High Schools Attended:
Name ______________________________________________________________________
Location ____________________________________________________________________
Dates ______________________________________________________________________
Name ______________________________________________________________________
Location ____________________________________________________________________
Dates ______________________________________________________________________
NOTE: To maintain a fair and equitable selection process, this sheet will be separated from the rest of your application upon receipt by the Secretary of the Selection Committee. The Secretary does not participate in the evaluation process, and will not reveal the information on this sheet until the winner has been selected.
(For Secretary's Use Only)
Code Number Assigned ___________
(Print out application utilizing your browser print function)