North Carolina Public School
Maintenance Association
JAY PALMER
SCHOLARSHIP TRUST FUND
HATS OFF TO YOU
Federal ID# 56-6346832
APPLICATION FOR JAY PALMER SCHOLARSHIP
NORTH CAROLINA PUBLIC SCHOOL MAINTENANCE
ASSOCIATION
Completed application should
be mailed to, Scholarship Chairman, C/O Handi-Clean Products, PO Box 988,
Greensboro, NC 27402
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
District- # _____
LEA Location- ____________________________
* 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
District- #
____
LEA location-
___________________________
* 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
District- #___
LEA Location- ___________________________
* 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 ___$100,001 and over
List other family
members attending school/college, etc.
Name
College or School Year to
Graduate Age
Sibling (s)
_______________
_______________ _____________
____
_______________ _______________
_____________ ____
_______________ _______________
_____________ ____
Father/Mother
_______________ _______________ _____________
____
_______________ _______________
_____________ ____
Dependent/Adopted
Children
_______________ _______________
_____________ ____
_______________ _______________
_____________ ____
E. High School Applicant
Attended/Attends______________________
Year of Completion
____________
F. College Attending or Applied to and
Accepted__________________
Years Attended _______ Year to Begin (Began) _________
Student ID#
____________________
* Address of college
or university/accepted to ___________________
_______________________________________________________
*Address where to send the
check (made out to the institution and applicant).
____________________________________________________________________________
* Include a copy of acceptance letter, required by all applicants.
G. Financial assistance from all other
sources_________________________________________
_____________________________________________________________________________
H. *Include applicants extracurricular
activities including, but not limited to academic, church, community, etc.
Please list on separate sheet.
I. *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 / University 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 written to the university and
applicant, mailed on or about the first week of August of award year.
*DENOTES REQUIRED INFORMATION TO BE
INCLUDED ON / OR WITH APPLICATION.
Applications must be
postmarked by February 28, 2014 and mailed to:
Scholarship Chair.
Larry McClain
C/O Handi - Clean Products
PO Box 988
Greensboro, NC 27402
Phone: 800-632-0269 or 336-292-3083
Fax: 336-292-3086