Application for Jay Palmer Scholarship

Application for Jay Palmer Scholarship

North Carolina Public School Maintenance Association

Completed application should be mailed to Clark Bunting, Scholarship Chairman, C/O Handi-Clean Products, PO Box 988, Greensboro, NC 27402

A. Applicants Name ________________________________________

Address_______________________________________________

Phone_________________________________________________

Date of Birth _____________ Age _________

Social Security # ________________________________________

Applicant Employer_______________________________________

Approximate Salary ___ 0-$10,000 ___$10,001-$20,000

___ $20,001-$30,000 ___$30,001-$40,000

___ $40,000-above

Current Member of NCPSMA ___ yes ___ no

Please include a copy of current NCPSMA membership card with

completed application.

B. If applicable:

Spouse ______________________________________________

Address _____________________________________________

Applicant Spouse Employer ______________________________

Work Phone Number ___________________________________

Approximate Salary ___ 0-$10,000 ___$10,001-$20,000

___ $20,001-$30,000 ___$30,001-$40,000

___ $40,000 -above

Current Member of NCPSMA ___ yes ___ no

Please include a copy of current NCPSMA membership card with

completed application.

C. Names/Addresses of Parents:

Father__________________ Mother_______________________

Address________________ Address______________________

Employer________________ Employer____________________

Work Phone______________ Work Phone__________________

Home Phone ______________ Home Phone _________________

Current Member of NCPSMA ___ yes ___ no

Please include a copy of current NCPSMA membership card with

completed application.

D. If applicant Dependant Child or Adopted Child

Parents Salaries (combined)

___$30,000-$40,000 ___$40,001-$50,000 ___$50,001-$60,000

___$60,001-$70,000 ___$70,001-$80,000 ___$80,001-$90,000

___$90,001-$100,000 ___$10,001 and over

Please list other family members attending school/college, etc..

Name College or School Year to Graduate Age

Sibling (s)

_______________ _______________ _____________ ____

Father/Mother

_______________ _______________ _____________ ____

Dependent Child/Adopted Child

_______________ _______________ _____________ ____

F. High School Applicant Attended/Attends______________________

Year of Completion ____________

G. College Attending or Applied to and Accepted__________________

Years Attended _______ Year to Begin _________

Address or college or university accepted ______________________

If winner, where to send the check made out to the institution and

applicant, to be mailed on about the first of August of said year.

*APPLICANT REQUIREMENT*

If you do not meet the following, please do not apply.

1. NCPSMA current member and employee of Maintenance

Department of North Carolina Public Schools LEA, or spouse of,

or dependent child of said listed employee member.

2. Financial need.

3. Acceptance by college or university

4. If application is not filled out completely and honestly, it will not be

considered.

H. Financial assistance from all other sources________________

________________________________________________________

I. Applicant extracurricular activities including, but not limited to

academic, church, community, etc. Please list on separate sheet.

J. Briefly convey in 200-500 words or less on a separate sheet your

hopes, wishes and desires, along with why you chose the college you

plan to attend.

Application must be postmarked by February 28, 2009 and mailed to Clark Bunting, Scholarship Chairman, C/O Handi-Clean Products, PO Box 988, Greensboro, NC 27402. Phone 800 632 0269 or 336 292 3083. Fax 336 292 3086.

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