AASC Scholarship Form

Step 1 of 2

Name *

First

Last

Address (Permanent Residence) *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Sponsoring Safety Organization (Please click in box for dropdown menu) *

Please refer to the scholarship requirements. Which of these relationships to the above sponsoring safety organization applies to you? *

Employee
Family member of the employee
Board member
Family member of board member
Employee of an organization that is a member company
Family member of an organization that is a member company

Please list the name of the family member or board member, and your relationship to them. If you are the employee or board member, list your name. If your relationship is through a member company of a sponsoring safety organization, list the member company name. *

Name of college/university that you attending *

College/University address *

Current Grade Level (Please click in box for drop down menu) *

List school and/or community organizations in which you have been actively involved: Name of Group and (Start/End) Dates of Participation *

List positions of leadership and start/end dates you have held in school or community organizations: *

List awards and commendations you have received, reason why and date received *

List your intended career path and specific degree or certification you are seeking. *

Please type in 500 words or less why health and safety are important in your life and in your chosen career. *

You must include with your application a copy of your most recent college transcript that shows your GPA. *

Click or drag a file to this area to upload.

The scholarship award winner will be notified by June 1. The scholarship award winner will have a $1500.00 check mailed to them at the permanent residence address above.

Date of application - (Failure to submit completed application and required documents will result in an immediate disqualification) *