A. Applicants Name ________________________________________

Address________________________________________________

Phone__________________________________________________

E-mail address __________________________________________

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 _________________

E-mail address _________________________________________

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/Adopted Children

_______________ _______________     _____________         ____

_______________ _______________     _____________         ____

F. High School Applicant Attended/Attends______________________

Year of Completion ____________

G. College Attending or Applied to and Accepted__________________

Years Attended _______ Year to Begin _________

Address* of college or university/accepted to ___________________

_______________________________________________________

*Where to send the check made out to the institution and applicant.

Include a copy of acceptance letter.

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 on a separate sheet your hopes, wishes and desires for your

academic and professional future, along with why you chose the college you plan to attend.

Please fill out completely and honestly. Incomplete applications will not be considered.

Recipients will be announced or notified by the end of June each year. If awarded scholarship,

check will be mailed at the beginning of August of award year.

Clark Bunting, Scholarship Chair

C/O Handi-Clean Products

PO Box 988

Greensboro, NC 27402

Phone: 800-632-0269 or 336-292-3083

Fax: 336-292-3086