APPLICATION FOR
the
ANTHONY & JOSEPHINE CHMURA MEMORIAL SCHOLARSHIP
of the
Marie Sklodowska Curie Professional Women's Association, Inc.
Applicant's Full
Name_________________________________________________________________________________
Address___________________________________________________________________________________________
City__________________________________________
State_____________________ ZIP_____________________
Country/Countries of
Citizenship_________________________________________________________________________
E Mail
Address______________________________________________________________________________________
U.S. Permanent Resident Alien Registration Number__________________________________________________________
Date of Birth_____________________________________________ Tel. No.___________________________________
Name of Spouse (if married)____________________________________________________________________________
Do you or a family member hold membership in the MSCPWA,
Inc.?_____________________________________________
(membership not a requirement)
If yes, give name and relationship
________________________________________________________________________
Name of High School (if applicant is a High School Senior):
School____________________________________________________________________________________________
Address___________________________________________________________________________________________
___________________________________________________________________________________________
Date of Graduation________________________________________
College, University, Vocational/Trade School, Institute, where
you are currently enrolled or are applying
to:
Name_____________________________________________________________________________________________
Address___________________________________________________________________________________________
___________________________________________________________________________________________
Date of enrollment______________________________________ Full or part
time student _________________________
Current level of
education______________________________________________________________________________
What course of study or profession are you pursuing?
__________________________________________________________________________________________________
Anticipated date of
graduation?__________________________________________________________________________
Expected degree or
certificate___________________________________________________________________________
Expected Expenses for the academic year:
Tuition
_____________________________________
Books and
Fees
_____________________________________
Room and
Board
_____________________________________
TOTAL EXPECTED EXPENSES
_____________________________________
Special circumstances (if any) demonstrating need
____________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Tuition to be financed
by____________________________________________________________________________________
__________________________________________________________________________________________________
Father's Full
Name________________________________________________________________ Living?
_____________
Mother's Maiden Name
____________________________________________________________ Living?
_____________
Check if of Polish
Descent: Mother
(
)
Father ( )
List memberships in clubs and
organizations:_________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
List honors, awards, and special
achievements:_______________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________________
Please write a short autobiography including goals/
ambitions, aptitudes, talents, accomplishments, membership in
organizations and
volunteer service (if any) in and out of school and why you are seeking a
higher education.
(Use separate sheets of paper.)
It is my understanding that the scholarship grant does not
obligate me to return said grant.
However, I do pledge that I shall
support the educational fund of the MSCPWA, Inc. when my career
goals are completed.
I hereby certify that the information provided above in support of my application for the
Anthony and Josephine
Chmura Memorial
Scholarship is, to the best of my knowledge, complete and
correct. I authorize the MSCPWA, Inc. to verify my information.
__________________________________________________
________________________________
Signature of Applicant
Date
IMPORTANT INFORMATION TO APPLICANT
1. Application must be submitted with the following documents:
a. Latest official transcript
b. Two recent letters of reference (Letters from family
members are not acceptable.)
c. Photograph
2. Enclose non-refundable $15.00 application fee made payable to MSCPWA, Inc.
3. Application must be TYPED or PRINTED in ink. Replies
must be legible and complete.
An incomplete application will not be
submitted to the Committee for approval.
4. Please return completed application, autobiography,
transcript, references, photograph and application fee
postmarked no later than Monday, November 29,
2010 to:
MSCPWA, Inc., Scholarship Committee
c/o Polish National Alliance of Brooklyn, USA
155 Noble Street
PO Box 22-9006
Brooklyn, New York 11222-9006