Please print this application and mail completed applications to: Suburban Maryland BPW, Scholarship Committee, 282 New Mark Esplanade, Rockville, MD 20850-2733.
Please Print:
Have you been a recipient of a BPW scholarship? Yes _____ No _____I. PERSONAL DATA
Name: __________________________________________________________________________ Present Address: _______________________________________________________________ City: ______________________________ State: __________ Zip Code _______________ Permanent Address (if different): ______________________________________________ Work Phone: __________________________ Home Phone: ____________________________ Social Security Number _________________________ U.S. Citizen: Yes _____ No ____ Place of Birth: ________________________________ Date of Birth: ________________ Marital Status: Single _____ Married _____ Sep/Div/Widow _____ Ages of any dependent children: ________________________________________________ Other dependents: ______________________________________________________________ Where did you learn about this scholarship? ____________________________________ II EDUCATIONAL PROGRAM FOR WHICH SCHOLARSHIP IS REQUESTED Name of Institution: ____________________________________________________________ Address: ___________________________________________ Phone: _____________________ Date course or term is scheduled to begin: Month __________________ Year ________ Description of training or education to be undertaken: _____________________________ ___________________________________________________________________________________ Degree or certification to be received: ___________________________________________ Will you attend: Part-time _________ Full-time __________ How many hours per semester or term? _____________________________________________ When do you expect to complete the course of study? ______________________________ III FINANCIAL INFORMATION Applicant's income, as reported on your most recent tax return $____________________ Total income, as reported on most recent tax return $_____________________________ Estimated annual expenses for which scholarship is requested: Tuition $_____________________ Fees $_____________________ Books and Supplies $_____________________ Transportation $_____________________ Child Care $_____________________ Other (specify) $_____________________ Other Sources of Financial Aid (Check one) Source Amount Granted Pending _________________________________ $__________ _______ _______ _________________________________ $__________ _______ _______ _________________________________ $__________ _______ _______ _________________________________ $__________ _______ _______ Amount applicant is able to contribute: $__________ IV EDUCATIONAL BACKGROUND Check the highest level of education achieved: Some High School _______ High School Graduate _______ GED _______ Some College ___________ College Graduate ___________ Name of previous institution(s) and type of program: ____________________________ _________________________________________________________________________________ Degrees, Diplomas, and Certificates List in chronological order all schools or training courses you have attended
since high school. Insert extra pages if additional space is required. Please
do not substitute a resume. Year Name of Institution If Graduated, If not Graduated, From/To and Location Field of Study # hrs completed GPA _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ V WORK EXPERIENCE List work experience since high school or for the last six years, starting with
most recent. A chronological resume may be substituted. Dates Job Title Name of Employer Full or From/To and Salary and Location Part-Time ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are you planning to work while you continue your education? Yes ____ No ____ If yes, will you work: Full-time ______ or Part-time ______ VI VOLUNTEER EXPERIENCE (if any) _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ VII PERSONAL STATEMENT A. Please briefly include major activities and interests for the past two years. B. On a separate sheet of paper, please discuss how you expect the proposed
education or training to add to your opportunities for advancement or employment. C. I certify to the best of my knowledge the information contained in this
application is true and correct. I also permit the Scholarship Committee to
contact any source listed in this document. I understand that the application
will not be considered unless it is signed and dated.______________________________________ Signature of Applicant ______________________________________ Date