Please type:
Name: _____________________________________________________________
Home Address: ______________________________________________________
_______________________________________________________ Zip_________
Telephone
(Work): ______________________ (Home): _________________________________
Name and address of present employer, if applicable: _________________________
Social Security Number: _________________________
Education
Degree: ___________________________ Date Received: ______________________
Institutiona; ___________________________________________________________
In which ALA - accredited graduate school are you currently enrolled? ____________
_______________________________________________________________________
Please list course titles and credits completed and those in which you are currently enrolled (a minimum of 18 credit hours MSUT be completed by the end of May of the current year). Attach additional sheets if necessary.
| Course Title | Credit Hours |
| Credit hours in progress | Completed |
Please list membership in professional and other organizations, honor societies, scholarships and/or other honors you have been awarded, attendance at youth servces conferences and workshops. Please list dates where applicable. Attach additional sheets if necessary.
Please list related community, civic, and volunteer experience. Please list dates.
Where did you learn about this scholarship?
Are you either a U.S. citizen or an alien who has/will have the legal right to work as a professional librarian in New York State after obtaining your MLS degree? _______________
I have read the instructions with this application and certify that the above statements are correct and complete. I understand that the Scholarship Committee will maintain this information as confidential.
Signature ____________________________________________________________
Date _____________________________