The Delta Kappa Gamma Society International
Alpha Gamma State Scholarship Application Form

Click here for a downloadable form in Word

(Information is requested to be typewritten. Send seven copies of the form to the Chairman of the Alpha Gamma State Scholarship Committee. Be sure to answer all pertinent to your situation.)

Name ______________________________________________________________________________
Address _____________________________________________________Zip Code_________________
Date of Birth ________________________________________ Telephone (____) ___________________
Chapter in which you are active __________________________ Initiation Date ___________________
Current (or most recent) position _________________________________________________________
Scholarship requested for Graduate Studies _______ Other (explain) ____________________________________ _________________________________________________________________________________________
_________________________________________________________________________________________

IF GRADUATE STUDY
Major Field ______________________________________________________Academic Year _______________
Institution where program will be pursued ___________________________________________________________
1. Officially admitted to graduate school? Yes _____ No _____
2. Date course work begun (or anticipated date) ____________________________

If started, number of hours beyond Bachelor _________________ GPA______

3. Concise statement of your program as approved: _______________________________________

_______________________________________________________________________________
_______________________________________________________________________________
4. Can this program be completed in the year during which you would hold this scholarship? _____

If no, how much longer is needed? __________________

5. Are you currently receiving other financial aid (scholarships, grants, etc.)? ______

If so, please give details including amounts received and source of aid. __________________________

_______________________________________________________________________________

_____________________________________________________

When will this aid terminate? _______________________________________________________

6. Please outline (on separate sheet if necessary) your plans for graduate study if you are selected for a scholarship. State how the advanced work will benefit you in your career plans. _______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

IF WORKSHOP, SEMINAR OR RETRAINING

Title of workshop _____________________________________________________________________
Sponsoring Agency ____________________________________________________________________
Purpose _____________________________________________________________________________

____________________________________________________________________________________

Location ____________________________________________ Date/s ____________________________

ALL APPLICANTS

I hereby request $_______________ for ___________________________________________________. (not to exceed $1,500.00)

Anticipated expenses:

Registration _____________________
Travel _____________________
Living Expenses_____________________
Miscellaneous (describe) _____________________ =======================================
TOTAL _____________________

I will attend even though I receive only partial funding Yes _____ No _____
For the benefit of the Society, I can contribute the following:

an article for the newsletter ________________________________
a program for a chapter meeting ________________________________
other _______________________________________________________

EDUCATION

Summary of higher education (academic, technical, and professional):

EXPERIENCE

List in chronological order the educational positions you have held, including all teaching, supervisory and administration positions:

List any other professional or business positions you have held, giving the type of position, place, and length of employment. ___________________________________________________________________________________________
___________________________________________________________________________________________

List other work, travel, or study experiences you wish the Committee to consider. _____________________________

___________________________________________________________________________________________

______________________________________________________________

List published writings (including articles and reviews) giving title, publisher, and date. ____________________________

____________________________________________________________________________________________

________________________________________________________________

PROFESSIONAL AND COMMUNITY ACTIVITIES AND HONORS

List any scholarships and fellowships you have received, stating in each case the place and date, name of project covered, and amount of stipend. __________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

List positions held and/or services rendered to The Delta Kappa Gamma Society at chapter, state, or international level. ___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

List professional, community, and other organizations of which you are a member, together with services rendered to each. Include offices held and other pertinent data. _____________________________________________________________________________________________
______________________________________________________________________________________________
_______________________________________________________________________________________________ _______________________________________________________________________________________________

REFERENCES

List in the space below the names and addresses of at least three persons who are submitting letters of recommendation on your behalf. Include your chapter president and, for graduate study, include one major professor.

Chapter President _______________________________________ Position _________________________________

Address/City/State/Zip ___________________________________________________________________________

Phone (_________)___________________________________

Major Professor or Name_______________________________________ Position ____________________________

Address/City/State/Zip ___________________________________________________________________________

Phone (_________)___________________________________

Name_________________________________________________ Position _________________________________

Address/City/State/Zip ___________________________________________________________________________

Phone (_________)___________________________________

Name_________________________________________________ Position _________________________________

Address/City/State/Zip ___________________________________________________________________________

Phone (_________)___________________________________

Be sure to include a small, recent photograph (not a snapshot) and, for graduate study, a copy of the admission statement from the graduate school you will attend.

Judy Lester, Chair
Alpha Gamma State Scholarship Committee
128 Honeysuckle Drive, Pikeville, KY 41501

Last Updated - February 1, 2012
Stephanie Greathouse, Webmaster