PLEASE PRINT YOUR FULL NAME IN THE ORDER INDICATED

PLEASE PRINT THIS FORM AND TAKE A COPY TO
X PLEASE COMPLETE THE REQUIRED INFORMATION IN ADDITION THE
6 COVER SHEET (PLEASE USE THIS SHEET

ACC 4152 IMPAIRMENT ASSESSMENT (ACCREDITED EMPLOYER) REPORT PLEASE
Associate Application Form (please Print and Complete
BLACK HISTORY MONTH 2007 EVALUATION FORM PLEASE

PLEASE print your full name in the order indicated.

Family Name First Name Middle Name

HOME ADDRESS:

Street and Number City State Zip Code

E-mail :__________________________________ Tel:____________________________

HIGH SCHOOL:

Application for a

SCHOLARSHIP

PROFESSIONAL ENGINEERS SOCIETY OF MERCER COUNTY

A CHAPTER OF THE NEW JERSEY SOCIETY OF PROFESSIONAL ENGINEERS

AWARD of the Scholarship shall be based upon character, general ability, scholarship, and financial need. The successful applicant for the scholarship will be notified on or about February 24, 2021.

SINCE THE AWARD is subject to the candidate’s meeting the entrance requirements for an engineering curriculum of a college or university of his or her choice, the candidate must file formal application for admission therein.

YOU MAY prepare this application form in your own handwriting or electronically. The application may then be returned to the email address below. Please request that your Guidance Counselor submit Page 5 and/or their recommendation separately to one of the two email addresses below:

Michael J. Marano, P.E.

c/o PESMC Scholarship Program

[email protected] or

[email protected]

THIS APPLICATION must be sent before 11:00 PM on February 17, 2021.

NOTE: Applicants are advised that a scholarship will not be awarded if the applicant receives more than 70 percent of his/her Cost of Attendance (COA) for the 2021-20222 academic year from other awards and grants. The scholarship award will be made after enrollment in an engineering school and other scholarship awards are verified.

Date 20 Date of Birth Citizen of

Name

Address

Father’s Name

Fathers Occupation

Mother’s Name

Mother’s Occupation

How Many Brothers and Sisters Do You Have Older Than You? Younger?

COLLEGE PREFERENCES List those colleges you are interested in attending in the order of your preference.	Date applied for Admission	Date Accepted (If available)

What branch of engineering are you going to study?

Activities: List your high school and community activities (other than jobs) in the order of interest to you that you have been involved in since entering high school. (Please continue on a separate sheet if required). Examples of activities would include Math Club, Athletic Teams, etc.

________________________________________________________________________________

Activity Hrs. Per Wk. No. of Yrs.

________________________________________________________________________________

Your most significant contribution

________________________________________________________________________________

Activity Hrs. Per Wk. No. of Yrs.

________________________________________________________________________________

Your most significant contribution

________________________________________________________________________________

Activity Hrs. Per Wk. No. of Yrs.

________________________________________________________________________________

Your most significant contribution

________________________________________________________________________________

Honors. List any special honors and awards you have won, either in or out of school, since you have entered high school.

Description of Honor or Award	Date Awarded

Work Experience. List the part-time and summer jobs you have held since entering high school.