CSEA LOCAL 810

CLINTON COUNTY SCHOOL &

MUNICIPAL EMPLOYEES

SCHOLARSHIP APPLICATION

INFORMATION AND INSTRUCTIONS

To be eligible for this Scholarship a student must be the dependent of a dues paying member in good standings of the: Association of Clinton County School and Municipal Employees Local 810 CSEA. The following are Units included under the Local 810 Chapter AuSable Valley Central School Chazy Central School Clinton, Essex and Franklin County Library CVES (BOCES 10 month Support Staff) Mooers Highway Northern Adirondack Central School Northeastern Clinton Central School Peru Central School Plattsburgh City School Town of Beekmantown Town of Dannemora Town of Ellenburg Town of Peru Town of Saranac Saranac Central School Village of Rouses Point

To be eligible for this scholarship the student must be accepted in a 2 or 4 year college or a creditable Trade School Program post graduation from high school. This is a $500 scholarship which could be awarded to a soul recipient or spilt by 2 recipients dependent on the number of applicant's. The recipient of this scholarship must also show proof of successful completion of one full semester of post high school education and registration for the second semester. Payment of the award will be granted upon notification from the college showing these requirement has been met.

Please note for applications to be considered all questions must be completed. Please type or print in ink and application must be legible.

APPLICATION FOR SCHOLARSHIP (June 12th )

Parent or Guardian Information CSEA Member's Full Name ______________________________ Employees CSEA or Agency Shop ID# _____________________

Relationship to Applicant: ______________________________

Employees Work Location and Building: __________________ ___________________________

Employee’s Title: ____________________________________

Student Information

Last Name: _________________________________________

First Name: _________________________________________

Address: ____________________________________________

____________________________________________________

Home and/or Cell Number: ______________________________ Date of Birth: _________________

Attending High School: ________________________________ Page 1

Number of Family Members in Household (including you) _________

Number enrolled in college next year 2017-2018 (including you) _________

College or Trade School you plan to attend:

Name: _____________________________________________

Address: ____________________________________________ Have you received an acceptance letter? _________

What high school honors have you received?

1.)___________________________________________________

2.)___________________________________________________ 3.)___________________________________________________ 4.)___________________________________________________

What extracurricular activities have you participated in during high school?

1.)__________________________________________________________

2.)__________________________________________________________

3.)__________________________________________________________ 4.)__________________________________________________________

Page 2

What jobs experiences do you have? 1.)_________________________________________________________

2.)_________________________________________________________ 3.)_________________________________________________________ 4.)_________________________________________________________

List any community services you have been or are involved in:

1.)_________________________________________________________

2.)_________________________________________________________ 3.)_________________________________________________________ 4.)_________________________________________________________

I here by state the above information is true to the best of my knowledge.

Signature _____________________________________________ Date _____________

Page 3

Please attach the following items to your application:

1.) A signed summary which includes the following information: ~ Your reasons for applying for this scholarship. ~ Your reasons for your choosing the College or Trade School you have. ~ What you plan to major in and why ~ Your career goals.

2.) A letter of reference from a school employee or boss.

3.) An official transcript from your attending high school

* Send completed application and attachments to:

CSEA Local 810 Scholarship Committee Plattsburgh CSEA Satellite Office 6 Booth Drive Plattsburgh, NY 12901 c/o Mrs. Christina M. Coryea/Local 810 PLEASE NOTE: ALL INFORMATION RECEIVED WILL BE CONFIDENTIAL.