Ephraim G. Sless Memorial Fund

Scholarship Fund Application

DEADLINE DATE: MAY 1, 2009

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 CERTIFIED 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.

Name:______________________________________________ Date of Birth:___________________________

Permanent Address:__________________________________________________________________________

Marital Status:_________________________

Name of Pharmacy School Applicant Attends:_____________________________________________________

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Name and Address of Parent or Guardian:________________________________________________________

Phone Number Home:(_____)______-____________ Phone Number College:(_____)______-______________

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)

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            TOTAL INCOME ________________                                     TOTAL EXPENSES: _____________

Are you currently holding a scholarship or have you applied for a scholarship? Yes____ No_______

Please indicate those currently held and number of years:

List all honors and accomplishments which indicate good scholarship and list all school activities and clubs. Specify major off ices held in each what hew you held In your chapter and when?

PRE-PHARMACY:____________________________________________________________

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PHARMACY:________________________________________________________________

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

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Additional information you wish the Scholarship Committee to know:

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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.

Signature:_______________________________________Date:__________________________

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