Achievement Award Application Form

Achievement Award Application Form
APPLICANT NAME

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
CO-OP MEMBER NAME

First NameLast Name
Account #
Relationship to Applicant
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long has your family been a member of Chain Lakes Gas Co-Op?

List in chronological order the school(s) (high school, post secondary) you have attended, including the one you are now attending

Rows	Name of School	Address	From	To	Grades Completed
School:
School:
School
School

Institution you plan to attend

Rows	Please insert information here
School:
Full Address w/ Postal Code
Commencement Date
Length of Program
Course of Study
Degree / Diploma / Certificate

Applicant Signature & Date
Co-Op Member Signature & Date
Summary Note:
1. The application form must be signed and submitted no later than October 1
2. Be sure to include with this application the following:
  a. Two (2) reference letters from any combination of teachers, employers, coaches, or ministers, provided they are not relatives
  b. A 500 word essay discussing yourself and your goals
3. Email the completed application and supporting documents no later than October 1 to: scholarships@chainlakes.ca
www.chainlakes.ca

CHAIN LAKES GAS CO-OP LTD PH 403 784 3343 OFFICE@CHAINLAKES.CA BOX 60 TEES ALBERTA T0C 2NO
Should be Empty: