FWG, INC. DR. JOHN E.

MIKLOS SCHOLARSHIP
SAMPLE FORM ONLY APPLICATION
Completed application must be returned no later than May 1. USE A SEPARATE PAGE AND ATTACH TO APPLICATION IF YOU NEED MORE SPACE TO COMPLETE A RESPONSE TO ANY QUESTION.

APPLICANTS NAME ADDRESS:

SS#

HOME PHONE: HOW MANY?

MARITAL STATUS AGES:

DO YOU HAVE ANY DEPENDENTS?

*ATTACH A RESUME OF PAST WORK EXPERIENCE*

Current Work Status (Circle one): Current Employer: Employers Address: Phone: Applicants Yearly Income Position: Supervisor: Total Household Income Full-time or Part-time

(Total household income includes income from spouse, parents, subsidy and all other income, excluding child support).

FWG, INC. MEMBERSHIP STATUS

Year you became a member: FWG (State): Chapter member: Chapter Name Have you attended any FWG Annual Conference? __________ Year(s) attended: Have you received a Scholarship from FWG, Inc.? If so, when was the last award and to what school? Will you receive or have you applied for any grants, financial assistance or scholarships from another organization or your local FWG, Inc. Chapter. Please list below: SOURCE AMOUNT RECEIVED/OR/APPLIED FOR

APPLICATION TO BE MAILED TO THE FOLLOWING SCHOLARSHIP CHAIRMAN:

NAME & ADDRESS:

Page No. 23
Revised 6-23-12

Sample Form - Page 1

SPONSOR INFORMATION
SPONSOR, PLEASE COMPLETE THIS PAGE OF APPLICATION:
SPONSOR NAME: RELATIONSHIP TO APPLICANT: ADDRESS: HOME PHONE: WORK PHONE: EMPLOYER: POSITION: WORK ADDRESS: No. of conferences you have attended and the years

Sponsor, please list your activities in FWG, Inc. and provide any additional comments on the person you are sponsoring: (use additional pages if necessary).

________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________

ESSAY
TO HELP US IN OUR DECISION-MAKING PROCESS, PLEASE ATTACH A ONE-PAGE ESSAY TELLING US WHY YOU APPLIED FOR AND/OR NEED THIS SCHOLARSHIP (INCLUDE ANY SPECIAL CIRCUMSTANCES/NEEDS). ALSO INCLUDE ANY AREAS OF GOVERNMENT SERVICE IN WHICH YOU ARE, OR THAT YOU MIGHT BE INTERESTED.

REFERENCES
Name: Address: Name: Address: Name: Address: Provide three (Personal, Employer, Teacher, Advisor, etc.) Relationship: Phone: ( Relationship: Phone: ( Relationship: Phone: ( ) ) )

Page No. 24

Revised 6-23-12

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EDUCATION
College or University that you are presently or planning to attend: Address: Current Educational Level of Applicant: Tuition Amount (per semester or per class): Books/Materials/Labs: Total estimated costs per year: If yes, amount:

Will your employer reimburse you for all or part of your continuing education expenses?

Are you employed in or studying in the field of Public Administration, Political Science, or any other government related field? What is your major?

* PLEASE ATTACH A COPY OF YOUR COLLEGE/HIGH SCHOOL TRANSCRIPT *

ISSUE CHECK FOR SCHOLARSHIP AWARD AS FOLLOWS:

SCHOLARSHIP AWARD RECIPIENT Home Address: Mailing Address (if different from Home Address): City, State, Zip Code

NOTARIZATION
The information on this form is true and correct to the best of my knowledge and belief. Print Applicants Name: Signature of Applicant:

STATE OF FLORIDA COUNTY OF_________________ The instrument stated herein was acknowledged before me this , who is personally known to me or who has produced and who did (did not) take an oath. My Commission Expires: Signature Notary Public Stamp:
(date) by

as identification

Page No. 25

Revised 6-23-12

Sample Form - Page 3

SCHOLARSHIP AND APPLICATION GUIDELINES

1.

Applicant must be a member in good standing of FWG, Inc. or a member of the immediate family of an FWG, Inc. member. Sponsored applicants must submit a signed affidavit of sponsorship by the member. Immediate family means spouse or dependent child. Dependent child is defined as son, daughter, stepchild, eligible foster child, or adopted child. It is also defined as the members child, 24 years old or under as of the end of the application calendar year, enrolled as a full-time student at an accredited school. Dependent child is also defined as an unmarried child or a married child who is a member of the applic ants parent-member household. If applicant is a dependent child of a FWG member, applicant must provide proof of school enrollment, age and place of residence. Applicant must be a legal citizen of the United States and resident of the State of Florida, is a high school graduate or have obtained a GED. Applicant must have attended an accredited college, university, community college, or vocational institution. Prior recipients are eligible to apply, whether you are planning to be a full or part-time student. Applicants are required to be working in a public/governmental entity and/or enrolled in a curriculum of Public Administration, Political Science, or other government field. Scholarship recipients must maintain a Grade Point Average (GPA) of 2.0 (C) or better. Scholarships shall be awarded during the Annual Conference in the amount determined by the Scholarship Committee and approved by the Executive Board. Awards will not be announced prior to the Installation Banquet. Payment of award will be made directly to the successful applicant by July 15 following the Annual Conference. Scholarship recipients must sign a notarized affidavit stating that all funds for educational reimbursement regardless of their source shall not exceed the total cost of tuition, classes, lab fees and required books. Application form must be complete. If a section does not apply, write "not applicable." applications will not be considered. Incomplete

2. 3. 4. 5. 6.

7. 8.

APPLICANT CHECKLIST
Complete the attached application and forms in their entirety. Use this checklist and attach it to your application to make sure you have provided all of the necessary information to complete your application. Incomplete applications are unacceptable, and may delay or disqualify your application from being considered. The Applicant is responsible for the completeness of their application. You will need the following information: 1. _____ 2. _____ 3. _____ 4. _____ 5. _____ 6. _____ 7. _____ Application is complete with forms and notarized statement filled out and signed by the appropriate persons. Attach a copy of school transcript (include the cost per credit hour, how many hours being taken, lab fees, the cost and description of books required). Attach a business rsum. Include an essay stating the reason you would like to receive a scholarship from FWG, Inc. Include a statement describing your sponsors participation in FWG, Inc. activities and fundraisers. Information about the school you will be attending (school must be accredited). No blanks enter N/A if section does not apply.

Page No. 26
Revised 6-23-12

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FWG, INC. DR. JOHN E. MIKLOS SCHOLARSHIP FUND

AFFIDAVIT OF FINANCIAL AID VERIFICATION FORM
SCHOLARSHIP RECIPIENT: ADDRESS:

Applicants classes being paid for or reimbursed by employer? Date received Date received Amount Amount

YES

NO

Dr. John E. Miklos Scholarship Award: Date received Date received Amount used as of this date: Any reimbursable amounts due: YES NO Amount: Amount Amount

Total amount reimbursed from any source:

PLEASE PROVIDE ANY ADDITIONAL INFORMATION THAT YOU FEEL IS PERTINENT TO THIS AFFIDAVIT:

NOTARIZATION
I HEREBY CERTIFY THAT I HAVE DISCLOSED ALL FINANCIAL ASSISTANCE THAT I HAVE RECEIVED AS OF THIS DATE.

Signature
STATE OF FLORIDA COUNTY OF_________________ The instrument stated herein was acknowledged before me this , who is personally known to me or who has produced as identification and who did (did not) take an oath. My Commission Expires: Signature Notary Public Stamp:

Date

(date) by

Page No. 27
Revised 6-23-12

Sample Form - Page 5

FWG, INC. DR. JOHN E. MIKLOS SCHOLARSHIP FUND AFFIDAVIT OF EDUCATIONAL REIMBURSEMENT

SCHOLARSHIP RECIPIENT: ADDRESS:

NOTARIZATION I HEREBY CERTIFY THAT:

A. B. C. All funds which I receive for educational reimbursement, regardless of their source, do not exceed the total costs of annual tuition, lab fees, and required books only. If I fail to complete a course or drop a course after the allowed drop/add period established by the school, all associated course fees paid from Dr. John E. Miklos Scholarship funds will be reimbursed to FWG, INC. I shall be enrolled in a degree-awarding program at an accredited college and maintain a grade point average (GPA) of 2.0 (C) or better, or forfeit the remaining scholarship funds.

Signature

Date

STATE OF FLORIDA COUNTY OF_________________ The instrument stated herein was acknowledged before me this , who is personally known to me or who has produced and who did (did not) take an oath. My Commission Expires: Signature Notary Public Stamp:
(date) by

as identification

Page No. 27-A

Revised 6-23-12

Sample Form - Page 6