Scholarship Application Form

I. Personal Data
 
         Last                  First
   Name:                 

  Phone:  -
         Street                     City             State  Zip
Address:       


II. The Delta Kappa Gamma Society International
 
Applicant must have been a member at least three years
           Chapter          City
Member of:  
           Year  City                                 State
Initiated:   

Offices held and services rendered, Chapter Level:
           
           
           
           
            

Offices held and services rendered, State Level:
           
           
           

Conventions, Workshops: (Describe specific participation, responsibilities, and years)
Workshops:
           
           
           
           
           
State Conventions:
           
           
           
           
 
Regional Conferences:
           
           
           

International Conventions:
           
           
           
III. Education (Post High School)
 Name of Institution   Attendance Dates  Degree and Date Received       Major
   
   
   
Technical and professional Training:
   
   

IV. Experience
List in chronological order the positions in education that you have held, including 
supervisory and administrative positions:

      Name of Institution             Dates Held         Title of Position
         
         
         
        

Other Experiences (Travel, exchange programs, conferences, other):
      Description                                        Dates               
        
        
        

V. Recognition and Achievement
Publications:
          
          
          
Creative Productions (Performance, television, radio, exhibits, lectures, other):
          
          
          
Other special honors or recognition:
          
          
          

VI. Proposed Use of Scholarship
Institution where proposed graduate program or certification has been approved:
    Name:   For academic year: 
Concise statement of your project as approved:
          

VII. Future Plans
Include an outline of the approved project and your plans for advanced study.
Can the project be completed in the grant year?  Yes No
If No, enter additional year(s) needed: 

VIII. Additional Information
List any other facts or special conditions you would like to have considered:
          
          
          

IX. References
Two persons who may provide letters of recommendation (include chapter president):
         Last                  First
   Name:  
         Street                     City             State  Zip
Address:       
         Last                  First
   Name:  
         Street                     City             State  Zip
Address:       

Chapter President Signature _____________________________________  Date ____________

X. Other Applications
If you have applied or expect to apply elsewhere for any fellowships or scholarships
for the year covered by this application, state the facts regarding said applications:
         
                
 
 
APPLICANT SIGNATURE _____________________________________  DATE ____________

Instructions for Submission
Fill in form, print it out on your computer, get chapter president's signature, 
sign and send via US Mail to:

Nyla Adamson 
1901 Vintage Woods Court
Salt Lake City, UT 84117

Submission deadline: March 15