APPLICATION:
Personal Data:
Reason for Applying for funds: ______ Police Academy ______ Criminal Justice
Major
Name of College or Academy: _________________________
Dates attending: ______________
Name: ___________________________
Address: __________________________________________
Phone #: _________________________
Date of Birth: ___/___/___
Social Security #: __________________
Graduating High School: ______________________________
Year Graduated: ___________________
List all extra-curricular activities. Include awards won and offices held:
List any Community Service you performed:
Work History:
Employer:______________________________
Address: ____________________________________________
Dates From _________________ To _________________
Your Title: ___________________________________________
Salary $____________
Duties: ___________________________________________________________________
_________________________________________________________________________
Employer:______________________________
Address: ____________________________________________
Dates From _________________ To _________________
Your Title: ___________________________________________
Salary $____________
Duties: ___________________________________________________________________
_________________________________________________________________________
Employer:______________________________
Address: ____________________________________________
Dates From _________________ To _________________
Your Title: ___________________________________________
Salary $____________
Duties: ___________________________________________________________________
_________________________________________________________________________
Personal Statement:
Include an essay describing yourself and why you feel you should be
selected for this fund. State your financial need. Also explain if you will be
working while attending school and include your employer.
Submission:
Mail to:
The Jason. D. Conklin Memorial Scholarship Fund
P.O. Box 493
Monroe, NY 10950