Student Name (last)
(first)
(mi)
Student ID Number 
Home 
Address 
Telephone Number (Home) 
Telephone Number (School) 
E-Mail Address 
University Attending 
APSCUF/APSCURF Member Name 
Address
University 
Telephone Number (W)(
)
(H)(
)
Relationship to Applicant 
APPLICATION AND REQUIREMENTS
Number of Credits Completed
Name of University where credits were completed:

Degree 
Major 
If applicable, other degrees earned and university:

Grade Point Average
University Activities 


Community Activities 


Two (2) References – APSCUF/APSCURF members other than member listed above (enclose written references per instructions):
1. 
2. 
Essay - Topic: How My Education And Accomplishments Are Preparing Me For My Future Goals (500 words, typed and double-spaced). Please attach this application form to your essay. All materials submitted, including the essay, WILL NOT be returned.
STATE APSCUF SCHOLARSHIP PROGRAM REFERENCE LETTER FORM
To the student: Fill in your name, signature, student ID number and date. Give this reference letter form to an APSCUF/APSCURF member who knows you well, and make arrangements to pick up the completed reference that has been placed in a sealed, signed envelope. Enclose both signed and sealed reference forms with your completed application and essay in an envelope which must be postmarked by a recognized postal system no later than March 3, 2006.
| |
Student Name 
Student Signature 
Student ID Number 
Date  |
To the APSCUF/APSCURF Member: The student named above is applying for a State APSCUF Scholarship. The scholarship program is intended only for students of “family members” of an APSCUF/APSCURF member or a State APSCUF Staff member. The student is required to submit two (2) separate references from APSCUF/APSCURF members (not from his/her family) who can testify to the student’s educational experiences and/or accomplishments. You should complete this form, place it in a sealed envelope, sign your name over the sealed flap, and return it to the student so he/she can include it with the application and essay.
| |
Your Name 
Your Signature 
Department 
University 
Office Phone 
Date  |
Where would you place the student on this scale? Academics, service, extracurricular activities, and personal initiative – all may influence your ranking.
| 5 |
4 |
3 |
2 |
1 |
| one of the most exceptional students I've known, among the top 5% |
excellent student among the top 10-15% |
very good student among the top third half |
good student among the top |
fair student |
On a page stapled to this form, please tell the State APSCUF Scholarship Review Committee about how you know the student and why the student’s educational experiences and other accomplishments make him/her a good scholarship candidate. Thank you for your time and commitment.
STATE APSCUF SCHOLARSHIP PROGRAM REFERENCE LETTER FORM
To the student: Fill in your name, signature, student ID number and date. Give this reference letter form to an APSCUF/APSCURF member who knows you well, and make arrangements to pick up the completed reference that has been placed in a sealed, signed envelope. Enclose both signed and sealed reference forms with your completed application and essay in an envelope which must be postmarked by a recognized postal system no later than March 3, 2006.
| |
Student Name 
Student Signature 
Student ID Number
Date |
To the APSCUF/APSCURF Member: The student named above is applying for a State APSCUF Scholarship. The scholarship program is intended only for students of “family members” of an APSCUF/APSCURF member or a State APSCUF Staff member. The student is required to submit two (2) separate references from APSCUF/APSCURF members (not from his/her family) who can testify to the student’s educational experiences and/or accomplishments. You should complete this form, place it in a sealed envelope, sign your name over the sealed flap, and return it to the student so he/she can include it with the application and essay.
| |
Your Name 
Your Signature 
Department 
University 
Office Phone 
Date  |
Where would you place the student on this scale? Academics, service, extracurricular activities, and personal initiative – all may influence your ranking.
| 5 |
4 |
3 |
2 |
1 |
| one of the most exceptional students I've known, among the top 5% |
excellent student among the top 10-15% |
very good student among the top third half |
good student among the top |
fair student |
On a page stapled to this form, please tell the State APSCUF Scholarship Review Committee about how you know the student and why the student’s educational experiences and other accomplishments make him/her a good scholarship candidate. Thank you for your time and commitment.
STATE APSCUF SCHOLARSHIP APPLICATION CHECKLIST
Student’s Name 
| _____ |
received the Guidelines and Requirements, Application , 2 Reference Letter Forms and the Application Checklist |
| _____ |
completed the Application Form |
| _____ |
obtained your official university transcript |
| _____ |
wrote the required essay, 500 words, typed and doubled spaced (essay WLL NOT be returned to the applicant) |
| _____ |
completed the top portion of the two reference forms |
| _____ |
gave the two (2) reference forms to two (2) separate APSCUF/APSCURF members and made arrangements to retrieve them. Each reference must be in a separate sealed envelope, signed over the outside seal by the APSCUF/APSCURF member. |
_____ Send addressed a large envelope to:
| |
State APSCUF Scholarship Program C/O Director for Membership Services PO Box 11995 Harrisburg PA 17108 |
All materials must be postmarked by a recognized postal service no later than March 3, 2006.
_____ contained in this large envelope, addressed to the State APSCUF Scholarship Program, should be the following:
| ____ |
completed Application Form |
| ____ |
copy of your official transcript |
| ____ |
copy of your completed essay |
| ____ |
2 Reference Letter Forms in sealed envelops, which have been properly signed by the APSCUF/APSCURF member. |
| ____ |
1st Reference Letter Form/Sealed Envelope |
| ____ |
2nd Reference Letter Form/Sealed Envelope |
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Services and Benefits > 2006 State APSCUF
Scholarship Information
.............................................................................................................................................................................................................
APSCUF, 319 North Front Street, PO Box 11995, Harrisburg, PA 17108-1995 Phone (toll-free): 800.932.0587 • Phone (local): 717.236.7486 General FAX: 717.236.1883 • Contract Department FAX: 717.236.1459 |