NJEHA Conference Gary S. Strauss Scholarship Fund

NJEHA Conference Gary S. Strauss Scholarship Fund
Complete the application legibly and in its entirety. Illegible or incomplete applications will be rejected. Applicant must include a certified copy of the academic transcript with the application. Submit the completed application by the deadline of August 31st.
Name

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you an Active Member (in good standing) of the New Jersey Environmental Health Association?
Current Occupation:
Please list your last (2) places of employment
List financial assistance from other sources (including loans, municipal, county or state funding):
Type of educational degree currently being pursued?
List the college, university, or institution of higher learning in which you are presently enrolled:
Date of enrollment:
Anticipated date of completion:
List approximate educational expenses peryear:
Tuition
Books
Fees
Other
List your academic objectives:
List any civic groups, associations or any other community organizations or activities of which you are a member. Also note any special honors or awards received.
Certification by applicant:

I hereby certify that the information provided in this application, which you are authorized to verify, is true and correct, and I agree to notify the grantor of this scholarship of any material changes in the facts stated in this application.
Signature
Date

MonthDayYear
Date
Should be Empty: