Please enable JavaScript in your browser to complete this form.1Basic Info2Employee/Parent or Guardian Information3High School Data4Post Secondary School Data5Work Experience6Document Upload7Review & Sign 2022-2023 Academic Year Application Postmark Deadline is April 30th, 2022.Applicant DataFirst Name *Middle InitialLast Name *Permanent Home Mailing Address *City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip Code *Telephone *E-mail Address *Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920NextEmployee/Parent or Guardian InformationEmployee/Parent/Guardian First Name *Employee/Parent/Guardian Last Name *Company NameWork TelephoneEmployee/Parent/Guardian E-mail Address *Job TitleDepartmentEmployee/Parent/Guardian AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip CodeRelationship to ApplicantNextHigh School DataSchool Name *High School TelephoneGraduation Date *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920City *State *AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingNextPost Secondary School DataName 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/ University2yr. Community CollegeVocational-Technical SchoolGraduate SchoolClass standing in the 2019-2020 academic year: *1st year2nd year3rd year4th year5th year6th yearMajor or course of study:When do you expect to graduate?Degree sought: *Bachelor’sAssociateCertificateMaster’sPreviousNext 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 *123Employer/Position *From Month / Year *To Month / Year *Hours Worked Per Week *Was this a Paid Position? *YesNoEmployer/Position *From Month / Year *To Month / Year *Hours Worked Per Week *Was this a Paid Position? *YesNoEmployer/Position *From Month / Year *To Month / Year *Hours Worked Per Week *Was this a Paid Position? *YesNo 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 *123Activity *Number of Years *Awards / Honors *Office(s) Held Activity *Number of Years *Awards / Honors *Office(s) HeldActivity *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 TextPreviousNextGoals and AspirationsOn 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.Paste Goals & Aspirations Here *Upload Document Instead?YesNoGOALS AND ASPIRATIONS * Click or drag a file to this area to upload. Transcript InformationA 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 RecommendationApplicants 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 *123Letter 1 * Click or drag a file to this area to upload. Letter 2 * Click or drag a file to this area to upload. Letter 3 * Click or drag a file to this area to upload. Application ChecklistThe 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 CHECKLISTCompleted Student Application.Current complete transcript(s) of grades. Grade reports are not acceptable.Goals and aspirations essay.Letter(s) of recommendation.PreviousNextReview & SignALL 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 *Clear SignatureApplication Date:PreviousPhoneSubmit