*Note: The following is from our archived collection of older documents, and may not reflect the most current information.
Name (Last, First, Middle): __________________________________________________________
Phone: _______________________
Primary Email Address: __________________________________________________________
Alternate Email Address: __________________________________________________________
Present address: _____________________________________________ Eff. Until: _____________
Street __________________________________________________________
City, State/Province/Country, Zip/Postal Code
__________________________________________________________
Permanent address: ___________________________________________
Phone: ________________
Street __________________________________________________________
City State/Province/Country Zip/Postal Code
__________________________________________________________
Birth Date: ____ /____ /____
Marital Status: _________
Number of Dependent Children: _________
Number of Other Dependents: __________
Schools/Colleges|Name/Address Institutions| Dates|Diploma/|GPA|Subject Other| (Mo/Yr)|Degree|
__________________________________________________________ __________________________________________________________ __________________________________________________________
Please use extra paper if necessary
Describe briefly any independent study, research or thesis completed or in process:
__________________________________________________________ __________________________________________________________ __________________________________________________________
List the library schools to which you have applied: __________________________________________________________ __________________________________________________________
If you have already enrolled in library school, indicate: Date of enrollment: ___________
Date Degree Expected: ______
Credit Hrs. Completed: _______
Credit Hrs. Remaining: _______
Campus Activities (dramatics, athletics, publications): __________________________________________________________ __________________________________________________________
Honors, prizes, awards, honor societies: __________________________________________________________ __________________________________________________________
Are you an SLA member? ______ If yes, please indicate your chapter: ______________________
Have you applied for an SLA Scholarship in the past? ___ If yes, what year?______
Have you received other SLA Chapter or Division Awards or Scholarships?_____ If yes, please list: __________________________________________________________ __________________________________________________________
Other professional society or organization memberships: __________________________________________________________ __________________________________________________________
Please list below, last three positions held:
1. Name & Address of Library, Company, Etc: __________________________________________________________
Positions: _____________________________
Full Time: ______ Part Time: ______
Duties: __________________________________________________________ __________________________________________________________ __________________________________________________________
Salary: _____________
Employment Dates From: ___________ To: ___________
Reason For Leaving: __________________________________________________________
2. Name & Address of Library, Company, Etc: __________________________________________________________
Positions: _____________________________
Full Time: ______ Part Time: ______
Duties: __________________________________________________________ __________________________________________________________ __________________________________________________________
Salary: _____________
Employment Dates From: ___________ To: ___________
Reason For Leaving: __________________________________________________________
3. Name & Address of Library, Company, Etc: __________________________________________________________
Positions: _____________________________
Full Time: ______ Part Time: ______
Duties: __________________________________________________________ __________________________________________________________ __________________________________________________________
Salary: _____________
Employment Dates From: ___________ To: ___________
Reason For Leaving: __________________________________________________________
ESTIMATED INCOME AND EXPENSES:
Income: On a separate sheet of paper indicate your total estimated income while you are enrolled in library school. Itemize by savings, aid from family/spouse, government allotment, loans or scholarships already received, estimated work earnings, gifts, and other miscellaneous sources.
Enter your total estimated income: ____________________
Expenses: On a separate sheet of paper indicate your total estimated expenses while you are enrolled in library school. Itemize by tuition, fees, books and supplies, room and board, Transportation, recreation, clothing, personal expenses, and miscellaneous. Because expenses vary at different library schools, please prepare a separate list of expenses for each library school to which you have applied.
Enter your total estimated expenses: ___________, ____________, and ____________
To What Other Sources are You Applying for Financial Aid? __________________________________________________________ __________________________________________________________
What Are Your Plans for Self-Support While Enrolled in Library School? __________________________________________________________ __________________________________________________________ __________________________________________________________
I authorize investigation of all matters contained in this application and agree that if any misrepresentation has been made by me herein or the investigation results are not satisfactory, this application will be considered void and any scholarship offer withdrawn.
I agree to notify SLA of all changes in both my financial and academic status which occur during and after the period in which my application is being considered. I understand the Association may withdraw its offer of a scholarship if I fail to report such changes.
_________________________________________________________ Signature / Date
NOTE: Please mail the application to: Special Libraries Association, 331 South Patrick Street, Alexandria, VA 22314-3501 USA
SCH-1-95
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