Ephraim G. Sless Memorial Fund

Scholarship Fund Application

DEADLINE DATE: May 30, 2012

Chairman: Sharon Chan

INSTRUCTIONS: Please type or print plainly and return by deadline date. Consideration of late applications is not guaranteed by the committee. INCLUDE AN UP TO DATE TRANSCRIPT OF YOUR GRADES. Mail applications to the Memorial Fund Chairman. Mark the outside of the envelope “Scholarship Application” so that it may be turned over to the committee unopened. Selection of recipients of scholarships is solely within the discretion of the Alpha Zeta Omega Pharmaceutical Fraternity, and the Ephraim G. Sless Memorial Fund Scholarship Selection Committee.

ELIGIBILITY: In order to be eligible to receive scholarship assistance, the applicant and his/her chapter must be in good standing with the Supreme Chapter of the Alpha Zeta Omega Pharmaceutical Fraternity. The applicant shall have the responsibility of confirming the status for applicant and his/her chapter.

PART I - Personal information

Name ______Date of Birth ______

Permanent Address ______

Marital Status ______

Phone Number Home ______Phone Number College______

Name and Address of Parent or Guardian ______

Father’s Occupation______Mother’s Occupation______

Number in Family Household______Number in Family in Elementary and/or High School______

In College______Number of Brothers or Sisters Living in Household and working______

Parent’s gross income (to show financial need: indicate amounts, if any, from Social Security, disability or other income)_$______

Part II - Academic/ Extracuricular Information

Name of Pharmacy School Applicant AttendsChoose an item.

Current Major ______☐Pharmacy☐Non-Pharmacy

List all honors and accomplishments which indicate good scholarship and list all school activities and clubs. Specify major offices held in each. If additional space is needed, please type out on a separate page and submit with application.

PRE-PHARMACY

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

PHARMACY

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

List all church and community activities, including major offices and responsibilities

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

PART III - Financial information

Income
Cash on hand or savings / $
Assistance from family / $
Student's anticipated earnings / $
Other (please specify) / $
Total Income / $
Expenses
Tuition or fees / $
Books / $
Room and Board / $
Other (please specify) / $
Total Expenses / $

Do you own your own car?☐Yes ☐No

Do you commute to school?☐Yes ______(If yes, please specify method of transport) ☐No

Do you live in: ☐a dormitory ☐an apartment ☐at home ☐Other ______

Are you currently holding a scholarship? ☐Yes (If yes, please list below )☐No

Please indicate those currently held and number of years.

NAME OF SCHOLARSHIP (years)AMOUNT OF SCHOLARSHIP

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

Have you applied for other scholarships? ☐Yes (If yes, please list below)☐No

NAME OF SCHOLARSHIP AMOUNT OF SCHOLARSHIP

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

Part IV - Additional information you wish the Scholarship Committee to know

______

I hereby certify that the above information is true and correct and authorize the Alpha Zeta Omega Pharmaceutical Fraternity to investigate any information provided in this application and to contact the appropriate persons and entities named. I further agree to provide additional confirmation of information contained in this application upon request.

SignatureDate

Please send all application materials to:

Sharon Chan

474 Beacon St. Apt BF

Boston, MA 02115

Any issues/questions? Feel free to contact me at via

Cell: (732) 763-5633 or

E-mail:

Final Submission Checklist:

☐Completed application

☐Copy of transcript

NOTE:

  1. You do NOT need to submit any tax forms/ W-2 for this scholarship
  2. Unofficial transcripts are accepted. Transcripts do NOT have to come from the registrar's office.

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