The Delta Kappa Gamma Society International
Alpha Rho State (Oregon)
Dagmar Jeppeson Grant Application
March 1 Deadline

Dagmar Jeppeson, a charter member of Psi Chapter, taught in Portland for 42 years. Her sister established this grant in her memory, with the stipulation that it be given to a female of at least junior standing who is pursuing a career in early childhood/elementary through grade eight education. Please return this application to the sponsoring chapter by February 1 so they can send your completed application and a chapter nomination letter to the State Financial Awards Chair prior to March 1.

Sponsoring chapter and name, address, and phone number of contact person:

REFERENCES:  List three people (not relatives) and their positions, to whom you have given a reference form with an addressed, stamped envelope. References are to be mailed directly to the State Financial Awards Chair.

1.

2.

3.

PERSONAL DATA: 

Name:							
Current Address:

Permanent Address:

Telephone:						Fax:

Marital status:			e-mail:

Name of college or university, current academic level, and Grade Point Average:

Signature______________________________________		Date_______________

Revised 9/2012
Dagmar Jeppeson Grant Application (pg. 2)

On separate paper, type your response to each of the categories in this outline.

1. EDUCATION: 
	Give a summary of your education from high school to the present time, including places 		and dates.

2. ACTIVITIES AND ACHIEVEMENTS:
	A. Describe your high school and/or college activities and achievements.

	B. Describe your service to your community/organizations.

3. EMPLOYMENT HISTORY:
	
4. CAREER GOALS:
	A. Major field of study, type of degree sought, and probable completion date
	
B. Give further information, special circumstances, or financial obligations which you        wish the DKG Financial Awards Committee to consider.

Reminder:  Return both portions of your application to the contact person of your sponsoring chapter by February 1.  Please encourage your three references to mail their replies directly to the State Scholarship Chairman prior to March 1.

State Financial Awards Chairman 2015-2017:
	Martha Nicoloff
	242 Muirfield Ave. SE
	Salem, OR 97306
	503-999-2069
	nicoloff2@comcast.net

Rev. July 2015

The Delta Kappa Gamma Society International
Alpha Rho State (Oregon)

Jeppeson Grant Reference Form
March 1 Deadline

Applicant’s Name: ______________________________________________________

Personal Qualities					Upper 1/3	Middle 1/3	Lower 1/3
1. Shows evidence of good health			_________________________________
2. Shows care in personal appearance			_________________________________
3. Displays emotional stability			_________________________________
4. Demonstrates ability to work with people		_________________________________
5. Adjusts readily to new situations			_________________________________

Professional Qualities				Upper 1/2	Middle 1/3	Lower 1/3
1. Is punctual in her responsibilities			_________________________________
2. Has the ability to express herself orally		_________________________________
3. Is well organized					_________________________________
4. Has the ability to put ideas, concepts, and 
    directives into written form				_________________________________
5. Uses a positive attitude in her everyday
    relationships with others				_________________________________

Additional Information:
1. Your knowledge of this applicant is based upon:

2. Why do you think this applicant has the potential to succeed as an elementary educator?

3. Other comments:

_______________________________	___________________________	___________
	Signature					Position			      Date

This recommendation will be used solely for grant selection and will be held in strict confidence.

Reference form due date is March 1. Mail to:

Martha Nicoloff, 242 Muirfield Ave. S., Salem, OR 97306,  503-999-2069
	nicoloff2@comcast.net						(Rev. July 2015)