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Calgary / Southern Alberta Chapter #162

Scholarship

Part II: Application

Personal Information

Surname: __________________________ Given Names _______________________

Address: _________________________________________________________________

City: ___________________ Province: __________ Postal Code: ________

Phone: Res (___) ____-______ Bus: (___) ____-______ Ext: ______

E-mail: (1) _________________________ (2) ___________________________

Career Information

Current Employer: __________________________________________________________

Address: __________________________________________________________

Job Title / Position: __________________ Supervisor: __________________________

Supervisor’s Phone: (___) ____-______ E-mail: __________________________

Please provide a description of your job responsibilities:

__________________________________________________________________________

Have you ever been fired or asked to resign a position? Yes No

Reason: __________________________________________________________________

Please attach a separate sheet of paper with your employment history. Resumes are acceptable.

Education

List all post secondary education obtained and institutions attended. You can include all degrees, diplomas and certificates that you have already obtained (use separate sheet if necessary).

__________________________________________________________________________

List any professional / occupational training (use separate sheet if necessary).

__________________________________________________________________________

Reason for application for ASIS scholarship

Outline your educational or professional goals that caused you to apply for this scholarship. Include courses and professional programs you are currently undertaking and how your career will be enhanced when you reach your goals:

__________________________________________________________________________

Projected costs breakdown:

__________________________________________________________________________

Have you received any other scholarship or bursary funding? If so, provide details:

__________________________________________________________________________

VOLUNTEER INFORMATION

ASIS Member # _____________ How long have you been a member? __________

Describe any work you have done for ASIS including executive / volunteer positions:

__________________________________________________________________________

Describe other volunteer work you are involved with (professional, community, sports, etc):

__________________________________________________________________________

INFORMATION REQUEST

I hereby give permission to the_______________________________________________ (University, College, Professional school or Institute) to which I am currently accepted and/or attending to release financial aid and academic information contained in my student file to ASIS International Calgary, Alberta. The information is to be used by the scholarship committee to help determine eligibility for a scholarship.

Signature: _______________________________________

Declaration of Applicant

I have read the instructions and hereby make application for the ASIS Calgary Chapter Scholarship and I declare that:

a. I have answered all questions applicable to me and that all information is true and complete

b. I agree to allow my personal information and study plans to be released publicly if I receive the scholarship

c. All of the above statements on this Scholarship application are true to the best of my skill and knowledge.

Signature: _____________________________ Date: ________________________

NOTE: Ensure that you have included all necessary attachments. Refer to Part I “General Requirements” for a complete list of required documents.