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James L. McGovern or IACLEA Annual Scholarship Application

 

Completed application and attachments should be returned to IACLEA Annual Scholarships, Attn: Priscilla Shisler, 342 North Main Street, West Hartford, CT 06117-2507. All applications must be postmarked by March 31, 2012.  If you have questions about these scholarships and/or eligibility, please contact Priscilla Shisler at (860) 586-7517, ext. 549; Fax: (860) 586-7550; Email:

Personal Information
Last Name:
First Name:
Middle:
Mailing Address:
City:
State/Province:
Zip/Postal Code:
Country:
Telephone:
Email:
College/University:
Enrollment Status:

Full-time   Part-time
Class Status: Freshman    Sophomore     Junior     Senior
Current/Intended Academic Major:
Degree Sought: Associate  Bachelor    Other 
Anticipated Date of Graduation:         
Extracurricular Activities: (Clubs, sports, etc.)
(Note: you may also include high school activities)
Personal Interest/Hobbies:

Institutional Representative Recommendation

To the Institutional Representative: Please print (black ink) or type all recommendation information. Attach any supporting documentation/correspondence your wish.
Applicant Name:
Employment Status:

Part-time  Full-time    Other 

Employment Schedule: hours per
Position/Title:

Duties/Responsibilities:
How long has applicant been employed with your department?

Please tell us something about applicant:
IACLEA Institutional Representative
Rep. Name:
Position/Title:
Institution:
I have reviewed this application and hereby recommend the applicant for consideration for a Scholarship Award.
IACLEA Institutional

Signature:    Date

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