KAZIMOUR SCHOLARSHIP APPLICATION

Please Type
Name:                                                                                                                                                                   
            Last                                                             First                                                     Middle Initial

SS#:                                                             ANTSHE Membership Number: ______________________

Date of Birth:                                                                                 

Address:                                                                                                                                                                
            Street
                                                                                                                                                                      
            City                                                             State                                                 Zip

Phone:  (         )                                                                    (         )                                                                        
                                    Home                                                                                     Work

Institution:                                                                                                                                                               
                         Name

                                                                                                                                                                                
                         Address   (City, State, Zip)

Student Status:             2 yr. College                     4 yr. Coll/Univ                     Grad School

Please list any college of community activities
                                                                                                                                                                                
                                                                                                                                                                                
                                                                                                                                                                                
                                                                                                                                                                                
                                                                                                                                                                                

PLEASE ATTACH NOMINATION LETTER, PERSONAL STATEMENT, TRANSCRIPT (S) AND MAIL TO:

 Stacie Wolbert
Chair, Kazimour Scholarship Committee
Clarion University of PA
82 N 5th Avenue
Clarion, PA 16124

 Duplicate copies of the application may be made, however the applicant must be a member of ANTSHE with a valid membership number.