Alaska Water Well Association | Scholarship Application
Biographical Information
Name:
Social Security Number:
E-mail:
                           High School Graduation or Equivalent: yes no
Address:
City:
State: Zip Code:
Campus Address:
City:
State: Zip Code:
Home Phone:
Work: Campus:
Date of Birth:
Place of Birth:
U.S. Citizen:
yes no
Alaskan Resident: yes no
Current Education
Current School:
Address:
City:
State: Zip Code:
Dept Head / Advisor Name:
GPA: Current Class Standing: Dates Attended:
Academic honors and/or offices held:
Extra-curricular activities:
Education Goals
School you are planning to attend:
Location (city/state):
Degree Goal:
Expected Degree Completion Date:
Plans for Post-Graduate Education:
Other Circumstances / Special Considerations
Do you plan to work while attending school? yes no
Do you plan to pursue a career in the State of Alaska? yes no
Additional Activities and Work Experience
List activities in which you have participated in your school (publications, athletics, music, art, student government, and clubs).
College Activities
Include dates participated, offices held and any special awards and/or honors.
High School Activities
Include dates participated, offices held and any special awards and/or honors.
Volunteer Work
List community activities in which you have volunteered (e.g. church, crisis hot lines, peer groups, hobbies, athletics and
chorus participation).
Include Agency / Organization name, type of work, dates participated and number of weeks.
Employment Experience
List jobs (including summer employment) you have held in the past two or three years.
Include job and type of work, employer, approximate dates of employment, approximate hours per week.
Oath
Please read carefully and click submit.
To the best of my knowledge, I have provided complete information. I am an Alaskan resident and intend to remain so.
I agree to report any factors which could affect consideration of my application. I understand that failure to provide
accurate and complete information may void my application.
Alaska Water Well Association
P.O Box 113156
Anchorage, Alaska 99511
907-522-8324 Karen Henderson, Executive Secretary
mailto:[email protected]
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