EmailMe Form - Virginia M. Wagner Educational Award Application

APPLICANT DATA

Name *

First MI Last

Date of Birth *

MM / DD / YYYY

Address *

Street Address City State / Province / Region Postal / Zip Code

Primary Phone *

### - ### - ####

Work Phone

### - ### - ####

Email *

Marital Status

Maiden Name (if applicable)

How did you hear of this grant?

FAMILY MAKE-UP

Spouse's Name

Spouse's Occupation

Number of Children

Child's Age(s)

Mother's Name

Mother's Occupation

Father's Name

Father's Occupation

Number of Other Dependent Siblings

Dependent Siblings Age(s)

HIGH SCHOOL DATA

High School Name

Graduation Date

MM / YYYY

High School City and State

High School Phone Number

### - ### - ####

POST-SECONDARY SCHOOL DATA

Name of post-Secondary school in which you are enrolled. Use official school names, please do not abbreviate.

1 - School Name

1 - School City and State

2 - School Name

2 - School City and State

Year in School NEXT semester

Enrollment Status

Full-Time

Part-Time

Study Type

Undergraduate

Graduate

Post-Graduate

Major

Number of Semesters before graduation

Number of Credits before graduation

Expected graduation date

MM / YYYY

Degree sought:

Bachelors

Masters

Doctoral

Describe previous degree(s) earned (if any)

ESSAY

Attach a typewritten essay, limited to two pages, covering the following topics.

1. Why did you choose to enter this profession?

2. What is your ultimate goal in this profession?

3. How would this grant affect your educational plans?

4. What efforts have you and your family made toward obtaining your degree?

5. What unusual family or personal circumstances have affected your achievement in school, work experience, or your participation in school and community activities?

Upload your essay file (.PDF or Word file Only)

Or Copy & Paste your essay here

TRANSCRIPTS

An official transcript of grades for the past academic year must be sent with this application. Jpeg and PDF files are acceptable.

Transcript Upload (JPEG & PDF Files only

ACTIVITIES, OFFICES, HONORS, AWARDS

List all community or school activities in which you have participated without pay during the past four years (e.g. work at school or children’s school, civic or cultural organizations). Note special awards,

1. Actives/Offices/Honors/Awards

1. Active years

2. Actives/Offices/Honors/Awards

2. Active years

3. Actives/Offices/Honors/Awards

3. Active years

WORK EXPERIENCE

Describe your work experience during the past four years (if homemaker, please indicate). Indicate dates of employment for each job and approximate number of hours worked each week. List monthly amounts earned.

Work Experience

	Employer/Position	From Mo/Yr	To Mo/Yr	Hours Per Week	Earned Weekly
1
2
3
4

FINANCIAL

To be considered for the grant, this information must be filled out completely.

What do you estimate your total expenses to be THIS year?

What do you estimate your total expenses to be NEXT year?

How much of this amout is for:

Books
Room & Board
Tuition
Other (Specify)

If you anticipate higher expenses next year, please explain:

Amount you can provide from your earnings:

Amount your Spouse/Parents can provide:

OTHER FINANCIAL AID

Please list the name and annual amount of any grants or scholorships you have been awarded for the school year

Other Financial Aid

	Name of Award	School where award will be used	Award Amount	Granted	Pending
1
2
3

REFERENCES

Please list three references (not relatives), one of whom is a professor at the school you attend. Please attach letters of reference.

References

	Name	Occupation	Address/Zip Code	Phone Number
1
2
3

Letter of Reference Upload (PDF or Word Doc Only)

SIGNATURES

• I certify that all information provided in this application is complete and accurate to the best of my knowledge. I will notify the designated club to which I have submitted this application if there are any changes.

• I understand that this award is not a scholarship and is therefore taxable for citizens of the United States. (For more information, consult IRS publication 520.)

• I certify that this is the only application I have made this year for a Virginia M. Wagner Grant or for a Live Your Dream Award from this or any other Soroptimist club.

• I understand that my application becomes the property of Soroptimist International of the Americas, Midwestern Region. The application will be considered confidential unless the applicant grants Soroptimist written permission to release personal information for the purpose of publicizing the Soroptimist Virginia M. Wagner Grant. By typing or signing your name below, you adhere to the above requirements.

This certifies that I am a resident of Ohio, Illinois, Indiana, Wisconsin, Michigan, or Kentucky *

Date *

MM / DD / YYYY

Last 4 digits of your Social Security Number *

I have read and agree to the release of my information to the media including, but not limited to, newspapers, magazines, or other print or electronic media. *

Date *

MM / DD / YYYY

Last 4 digits of your Social Security Number *