Application Form for Vivian F. Bourgeois Special Stipend

(Send one photo of Applicant)

Dr.
Miss
Mrs. __________________________________________________________
Ms.                     Last                         First                          Middle

ADDRESS: ____________________________________________________
                                                Street or P.O. Box

                   _____________________________________________________
                                                City             State               Zip

Home Phone: (      )______________ Business Phone: (      )_____________

FAX Number: (     )______________ eMail Address: __________________

Primary Information:

        Date Initiated (Month and Year): ______________________________

        Present Chapter: ____________________________________________

        Verification by Chapter Treasurer and Chapter President:

            ________________________________________________________
            Signature of Chapter Treasurer (To Verify Payment of Current Dues)

            ________________________________________________________
            Signature of Chapter President (To Verify Chapter Involvement)
 
 
 

Current Professional Position:

        Place of Employment: _______________________________________

        Grade Level: ____________ Discipline/Subject: _________________

        Number of Years of Service to Education: ______________________
 

I. DELTA KAPPA GAMMA INVOLVEMENT: Summarize your Delta Kappa
Gamma involvement at each of these levels:

Chapter:
 
 
 
 
 
 
 
 

District:
 
 
 
 
 
 
 
 

State:
 
 
 
 
 
 
 
 

Regional/International:
 
 
 
 
 
 
 
 
 
 

II. PROFESSIONAL INVOLVEMENT AND ACHIEVEMENT:

A. Summarize your Educational Background by listing the academic degrees you
hold and indicating your areas of certification:

Academic Degrees:
 
 
 
 
 

Areas of Certification:
 
 
 
 
 
 

B. Summarize your involvement (memberships, offices held, etc.) in major
Professional Organizations other than The Delta Kappa Gamma Society International.
(Begin with the most recent. Do not use acronyms or initials.)

Organization                                                                     Involvement
 
 
 
 
 
 
 
 

C. Briefly summarize your Recognitions, Publications, and Special Achievements.
 
 
 
 
 
 
 
 
 
 
 
 
 

III. COMMUNITY INVOLVEMENT: Summarize the Membership and Offices held
in Community Organizations or Services rendered to the Community. (Begin with most
recent.)

Community Organization                                                     Involvement
 
 
 
 

IV. PROPOSED USE OF STIPEND: Provide the following information about your
proposed involvement at the Meeting:

Vivian F. Bourgeois Special Stipend Guidelines (February 10, 1996)

Purpose: To encourage Epsilon State members of The Delta Kappa Gamma Society International to
become better classroom teachers/professors by affording them the opportunity to present at or attend
regional, national, and international conferences/conventions or workshops/seminars within their discipline.
The meetings are to be those of significant educational organizations other than The Delta Kappa Gamma
Society International. Funding: Provided by interest accrued from the VIVIAN F. BOURGEOIS
SPECIAL STIPEND FUND. The amount, not to exceed $500 per recipient, shall be used to defray
expenses of registration, room costs, and travel. Availability of funds will determine the number of awards
per year.

A. Circle the type of meeting you plan to attend:

        Conference         Convention         Workshop         Seminar

B. Name of Organizational Meeting you plan to attend and dates:

        __________________________________________________________

C. Name of City and State where Meeting will be held:

        __________________________________________________________

D. Your Rationale for attending the Meeting: (How will your attendance at this
meeting impact your effectiveness as a classroom teacher/professor?)
 
 
 

E. Your Responsibility at the Meeting:

        Attendance Only

        Presenter at One or More Sessions

        Other (specify) __________________________________________

F. Anticipated Cost of Attendance:

        Registration Fee:       $ __________

        Travel Cost:               $ __________

        Hotel Room Cost:       $ __________

                    Total Cost:     $ __________

V. REFERENCES: (Do not send Letters of Reference. Provide information below.)

a. Chapter President (or Immediate Past President):

        Name: ___________________________________________________

        Phone: ___________________________________________________

b. Professional Referent (Principal, Supervisor, or Department Head):

        Name: _____________________________________________________

        Phone: _____________________________________________________

VI. APPLICANT AGREEMENT:

1. I certify that the information provided in this application is correct and that I am
forwarding the ORIGINAL and FIVE (5) COMPLETE SETS of the
Application Form to:

                    Dr. Virgie M. Dronet, Chairman
                    The Vivian F. Bourgeois Special Stipend Committee
                    P.O. Box 674
                    Lake Arthur, Louisiana 70549

2. If I am a successful recipient of a Vivian F. Bourgeois Special Stipend, I agree to file
a report with the chairman of the Special Stipend Committee within 30 days
following completion of the meeting. Included in the report will be documentation:

                a. Verifying expenditures (include receipts and invoices) covered by the award.

                b. Summarizing involvement at the meeting (meetings attended, sessions
                        presented, etc.) and describing proposed applications in my  classroom setting.

                        _________________         _______________________________
                                  Date                                      Signature of Applicant

DEADLINE FOR APPLICATION: (Remember to allow four weeks for processing
of Application Forms by the Committee.)