2021-2022 Academic Year

Application Postmark Deadline is March 5th, 2021.

Applicant Data

Name *

First

Middle

Last

Permanent Home Mailing Address *

Address Line 1

City

State

Zip Code

Telephone *

E-mail Address *

Date of Birth *//

Employee/Parent or Guardian Information

Employee/Parent/Guardian Name *

First

Last

Company Name

Work Telephone

Employee/Parent/Guardian E-mail Address *

Job Title

Department

Employee/Parent/Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship to Applicant

High School Data

School Name *

High School Telephone

Graduation Date *//

City *

State *

Post Secondary School Data

Name of school you plan to attend next year. (If unknown, please list in order of preference the schools to which you have applied.) Use official school names, do not use abbreviations.

Name of school *

City of the school *

State of the school *

Name of school (2)

City of the school (2)

State of the school (2)

Institution Type *

4yr. College/ University
2yr. Community College
Vocational-Technical School
Graduate School

Major or course of study:

When do you expect to graduate?

Degree sought: *

Bachelor’s
Associate
Certificate
Master’s

Work Experience

Describe your work experience during the past four years. Indicate dates of employment for each job and an approximate number of hours worked each week.

Number of Positions *

1
2
3

Employer/Position *

From Month / Year *

To Month / Year *

Hours Worked Per Week *

Was this a Paid Position? *

Yes
No

Activities, Awards & Honors

Describe your work experience during the past four years. Indicate dates of employment for each job and an approximate number of hours worked each week.

Number of Activities *

1
2
3

Activity *

Number of Years *

Awards / Honors *

Office(s) Held

Unusual Circumstances

Please describe if, how, and when any unusual family or personal circumstances may have affected your achievement in school, work experience, or your participation in school and community activities. (This field is optional)

Paragraph Text

Goals and Aspirations

On a separate sheet write an essay describing your education and career plans and how they relate to a safety and health career. This essay can be up to one standard page in length, single spaced with a 12 point font.

Upload Document Instead?

Transcript Information

A transcript of grades must be sent with this application. Unofficial transcripts must display student name, school name, grade and credit hours earned for each course, and term in which each course was taken. Grade reports are not acceptable.

Students currently or previously enrolled in college must include all college transcripts of grades from each school attended. High school information is not necessary.
High school seniors and students who have completed less than one full quarter or semester of post-secondary education must include a high school transcript of grades.

TRANSCRIPT INFORMATION *

Click or drag a file to this area to upload.

Letters of Recommendation

Applicants must submit at least one (1) letter of recommendation from:

a High School Counselor or College Advisor, a Teacher or Professor, a Leader or Supervisor of a community activity in which you were involved, OR an employer or prior safety supervisor.

Select number Of Letters *

Application Checklist

The student is responsible for submitting all by the scholarship deadline. Incomplete applications will not be evaluated. This application for scholarship becomes complete and valid only when the ESC Scholarship Committee has received all of the following materials:

APPLICATION CHECKLIST

Completed Student Application.
Current complete transcript(s) of grades. Grade reports are not acceptable.
Goals and aspirations essay.
Letter(s) of recommendation.

Review & Sign

ALL MATERIALS, INCLUDING TRANSCRIPTS, MUST BE ADDRESSED TO:

I acknowledge decisions are final. I certify I meet eligibility requirements as described in the brochure and that the information provided is complete and accurate to the best of my knowledge. If requested, I will provide proof of information on this form. Falsification of information may result in termination of any scholarship granted.

Applicant’s Signature *

Application Date:

Monty C. Lish & Stanley O. McNaughton Scholarship for Safety & Health Careers