NEED Scholarship Award for Community College and Trade School
ANS John & Muriel Landis NEED Scholarship Award for Community College & Trade School Students The NEED Scholarship Award for Community College and Trade School students is a $2500 award for students in twoyear programs. Up to four (4) awards will be made in 2015 for students who have greater than normal financial need. Please read carefully The scholarship application, official transcripts, letter of sponsorship, and three confidential reference forms must all be mailed together as a complete packet to ANS Headquarters, to the attention of the Scholarship Coordinator. Incomplete packets may not be considered. We recommend that you mail your application packet at least 7 days prior to the April 1 deadline. Mail the documents together to: Scholarship Coordinator American Nuclear Society 555 N. Kensington Avenue La Grange Park, IL 60526 Please use the check list below to make sure all necessary forms are in your application packet. Enclosed Application Official School Transcript(s) with seal Sponsorship letter from ANS organization or member Sponsorship for scholarship must be made by an ANS Local Section, Plant Branch, Student Section, or member to establish that the applicant is indeed a student and deserving of the funds provided by ANS for the scholarship. Confidential Reference Form #1 Confidential Reference Form #2 Confidential Reference Form #3 All of the above must be included to be considered a complete packet. 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School Please complete as an interactive PDF or print in black ink pen only Name (Last, First, Middle) _______________________________________________ Date____________________________ Other name(s) under which you have been employed __________________________________________________________ Present Address _______________________________________________________________________________________ City _________________________________________________________ State _________ Zip Code _________________ Home Phone (____) ______________Business/Cell Phone (____) ______________E-Mail____________________________ College/Trade School ___________________________________________________________________________________ Department of School ___________________________________________________________________________________ Address _____________________________________________________________________________________________ City _________________________________________________________ State _________ Zip Code _________________ Your Status in the Coming Academic Year Trade School Community College ___ 1st Year ___ Full time ___ Part time ___ 1st Year ___ Full time ___ Part time ___ 2nd Year ___ Full time ___ Part time ___ 2nd Year ___ Full time ___ Part time Permanent Resident Visa expiration date_______________________________________________ Where did you learn about the ANS Community College / Trade School Scholarships? Please be specific. Sponsoring Organization / Member (Sponsorship/nomination for scholarship is made by an ANS Local Section, Plant Branch, Student Section, or an individual ANS member to establish that the applicant is indeed a student and deserving of funds provided by ANS for the scholarship. You can find a list of ANS organizations with contact information at http://www.ans.org/const/ ) What ANS Organization is sponsoring your application? _____________________________________________________ Who is your contact in that organization? Name ____________________________________________________________________________________________ Address ___________________________________________________________________________________________ City _______________________________________________________ State _________ Zip Code _________________ Please ask your Sponsoring Organization to complete the form included in this application - see pages 6 & 7. American Nuclear Society Page 1 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School EMPLOYMENT HISTORY Account for all employment, including U.S. Military Service. Start with your most recent position and work backward. Indicate average number of hours per week for any position less than full time. Attach supplemental sheet, if necessary. Present or Last Position Name of Employer __________________________________________________________________________________ Address ___________________________________________________________________________________________ City________________________________________________________ State_________ Zip Code_________________ Name of Supervisor _________________________________________Telephone (______) ________________________ Your Position _______________________________________________From _______________To _________________ May we contact your supervisor regarding your qualifications? _____ YES _____ NO Your principal duties, accomplishments, and special equipment used (use an additional sheet of paper if necessary Previous Position Name of Employer __________________________________________________________________________________ Address ___________________________________________________________________________________________ City_______________________________________________________ State_________ Zip Code__________________ Name of Supervisor _________________________________________Telephone (______) ________________________ Your Position _______________________________________________From _______________To _________________ May we contact your supervisor regarding your qualifications? _____ YES _____ NO Your principal duties, accomplishments, and special equipment used (use an additional sheet of paper if necessary). American Nuclear Society Page 2 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School Financial Assistance List other financial assistance you will receive for the 2015-2016 school term and list all forms of Financial Assistance you are currently receiving: Type of Assistance Amount Date(s) of Assistance (i.e., Grant, Scholarship, etc.) (i.e., Sept. 2015-June 2016) Education and Training For attendance at a College, University, or Technical Institute, give the information requested for each undergraduate and graduate degree. If you did not receive a degree, but have some college training, please give dates in attendance and total hours completed. ALL TRANSCRIPTS OF RECORD MUST BE INCLUDED OR SENT TO BE RECEIVED BY APRIL 1, 2015. School __________________________________________ School __________________________________________ Location________________________________________ Location________________________________________ Dates in Attendance_______________________________ Dates in Attendance_______________________________ Major___________________ Hours Completed _________ Major___________________ Hours Completed _________ Minor ___________________________________________ Minor ___________________________________________ Degree _________________________________________ Degree _________________________________________ GPA ___________________________________________ GPA ___________________________________________ School __________________________________________ School __________________________________________ Location________________________________________ Location________________________________________ Dates in Attendance_______________________________ Dates in Attendance_______________________________ Major___________________ Hours Completed _________ Major___________________ Hours Completed _________ Minor ___________________________________________ Minor ___________________________________________ Degree _________________________________________ Degree _________________________________________ GPA ___________________________________________ GPA ___________________________________________ American Nuclear Society Page 3 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School REFERENCES List at least three people (preferably faculty members and/or supervisors) who are familiar with your qualifications (see form on Page 8). Please have each person send a letter of reference to ANS Headquarters, Attn: Scholarships, to be received by the April 1 deadline. Name ____________________________________________________________________________________________ Address ___________________________________________________________________________________________ Phone (_______) _________________________________E-mail _____________________________________________ Association with you _________________________________________________________________________________ Name ____________________________________________________________________________________________ Address ___________________________________________________________________________________________ Phone (_______) _________________________________E-mail _____________________________________________ Association with you _________________________________________________________________________________ Name ____________________________________________________________________________________________ Address ___________________________________________________________________________________________ Phone (_______) _________________________________E-mail _____________________________________________ Association with you _________________________________________________________________________________ Name ____________________________________________________________________________________________ Address ___________________________________________________________________________________________ Phone (_______) _________________________________E-mail _____________________________________________ Association with you _________________________________________________________________________________ American Nuclear Society Page 4 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School Personal Statement of Future Plans On this page, please provide a statement of your academic and professional goals, experiences that have affected these goals, and any other information that you think will aid the selection committee in evaluating your application. I certify that the information given in this application is correct and complete to the best of my knowledge. Date __________________________________ Signature _____________________________________________________ American Nuclear Society Page 5 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School Attachment 1, Page 1 of 2 Sponsoring Organization Form Attachment 1, Page 1 of 2 Please complete as an interactive PDF or print in black ink pen only PLEASE RETURN TO STUDENT BY March 20, 2015 Name of ANS Sponsoring Organization _________________________________________________ Date _______________ Name of Individual Contact ______________________________________________________________________________ Address ____________________________________________________________________________________________________ City ___________________________________________________________ State ___________ Zip Code _____________ E-mail ____________________________________________ Phone (______) _____________________________________ Name of Sponsored Student _____________________________________________________________________________ College/Trade School ___________________________________________________________________________________ Statement of Need The ANS COMMUNITY COLLEGE / TRADE SCHOOL SCHOLARSHIPS are intended for students who have a greater than normal financial need. The ANS NEED Committee also seeks to aid students who are disadvantaged for other reasons (e.g., inadequate high school or undergraduate preparation, etc.) Please describe the applicant’s financial need: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Please list conditions that cause the applicant to be otherwise disadvantaged (if any). ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ American Nuclear Society Page 6 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School Sponsoring Organization Form Attachment 1, Page 2 of 2 Use as an interactive PDF or print in black ink pen only PLEASE RETURN TO STUDENT BY March 20, 2015 Sponsoring Organization/Member Statement of Recommendation Why do you feel this student should receive the ANS Community College / Trade School Scholarship? __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ American Nuclear Society Page 7 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School CONFIDENTIAL REFERENCE FORM Applicant__________________________________________________________________________________________ (Last) (First) (Middle) For how long and in what association have you known the applicant? ___________________________________________ In a group of 100 students, how would you rate the applicant with respect to the following personal characteristics: Below Average Lowest 40 Average Middle 25 Above Average Next 20 Unusual/ Outstanding Highest 15 Inadequate observation time Motivation toward a successful productive career Fertility of imagination; originality of thought Emotional stability and maturity Ability to work with others Self-reliance and independence In a group of 100 students, how would you rate the applicant with respect to the following scientific capabilities: Below Average Lowest 40 Average Middle 25 Above Average Next 20 Unusual/ Outstanding Highest 15 Inadequate observation time Mastery of fundamental knowledge in major field Growth during total period observed Laboratory skill and technique Ability to communicate information (written/oral) In the space below, add any descriptive comments which will assist in providing a complete picture of the applicant’s character, attitude, abilities, and potential as an engineer or scientist. Please comment on the applicant’s weak as well as strong points. (Use additional sheets if necessary.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Signature _____________________________________________________________ Date ________________________ Type or print name __________________________________________ Title ____________________________________ Address __________________________________________________ Phone (______) ___________________________ Reference: Please return this completed reference form to the student in a sealed envelope prior to March 20, 2015 American Nuclear Society Page 8 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School CONFIDENTIAL REFERENCE FORM Applicant__________________________________________________________________________________________ (Last) (First) (Middle) For how long and in what association have you known the applicant? ___________________________________________ In a group of 100 students, how would you rate the applicant with respect to the following personal characteristics: Below Average Lowest 40 Average Middle 25 Above Average Next 20 Unusual/ Outstanding Highest 15 Inadequate observation time Motivation toward a successful productive career Fertility of imagination; originality of thought Emotional stability and maturity Ability to work with others Self-reliance and independence In a group of 100 students, how would you rate the applicant with respect to the following scientific capabilities: Below Average Lowest 40 Average Middle 25 Above Average Next 20 Unusual/ Outstanding Highest 15 Inadequate observation time Mastery of fundamental knowledge in major field Growth during total period observed Laboratory skill and technique Ability to communicate information (written/oral) In the space below, add any descriptive comments which will assist in providing a complete picture of the applicant’s character, attitude, abilities, and potential as an engineer or scientist. Please comment on the applicant’s weak as well as strong points. (Use additional sheets if necessary.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Signature _____________________________________________________________ Date ________________________ Type or print name __________________________________________ Title ____________________________________ Address __________________________________________________ Phone (______) ___________________________ Reference: Please return this completed reference form to the student in a sealed envelope prior to March 20, 2015 American Nuclear Society Page 8 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org 2015-2016 School Year ANS NEED Scholarship Award Individual Application for Community College/Trade School CONFIDENTIAL REFERENCE FORM Applicant__________________________________________________________________________________________ (Last) (First) (Middle) For how long and in what association have you known the applicant? ___________________________________________ In a group of 100 students, how would you rate the applicant with respect to the following personal characteristics: Below Average Lowest 40 Average Middle 25 Above Average Next 20 Unusual/ Outstanding Highest 15 Inadequate observation time Motivation toward a successful productive career Fertility of imagination; originality of thought Emotional stability and maturity Ability to work with others Self-reliance and independence In a group of 100 students, how would you rate the applicant with respect to the following scientific capabilities: Below Average Lowest 40 Average Middle 25 Above Average Next 20 Unusual/ Outstanding Highest 15 Inadequate observation time Mastery of fundamental knowledge in major field Growth during total period observed Laboratory skill and technique Ability to communicate information (written/oral) In the space below, add any descriptive comments which will assist in providing a complete picture of the applicant’s character, attitude, abilities, and potential as an engineer or scientist. Please comment on the applicant’s weak as well as strong points. (Use additional sheets if necessary.) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Signature _____________________________________________________________ Date ________________________ Type or print name __________________________________________ Title ____________________________________ Address __________________________________________________ Phone (______) ___________________________ Reference: Please return this completed reference form to the student in a sealed envelope prior to March 20, 2015 American Nuclear Society Page 8 Receipt of Application Deadline – April 1, 2015 555 North Kensington Avenue • La Grange Park, IL 60526 USA Phone (800) 323-3044 • Fax: (708) 579-8238 • Website: www.ans.org
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