SCHOLARSHIP APPLICATION

MUSEUM OF SURVEYING

North American Surveying History Scholarship

Awarded in Memory of Patrick Benton

Application must be received by November 1

 

Applicant Name__________________________________________________________________

                                            Last                                         First                                       Middle

Mailing Address__________________________________________________________________

City___________________________________ State_____________ Zip Code_______________

Social Security # (or equivalent)_______________________ Date of Birth________________

Home Phone (______)____________________ Work Phone (_______)_____________________

Fax (______)______________________ Email__________________________________________

Please mail entire application to:

MUSEUM OF SURVEYING

220 S. Museum Drive

Lansing, MI 48933

College/ Post Secondary:

School/ Program/ Department _____________________________________________________

Address__________________________________________________________________________

Phone (_____)___________________ Faculty Advisor___________________________________

Curricula_______________ Full Time (minimum 12 semester hrs) _______ Part Time ______

Major or Field of Study__________________________ Current Degree____________________

Academic Class: ___Sophomore ___Junior ___Senior Tentative Graduation Date__________

Current Grade Point Average (Base on 4.0 = A)_____________ as of (date)________________

 

 

List any scholarship, fellowship, or tuition and fee waiver, which you will receive during the academic year (Amount and Award)

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

Estimate fees for Room/ Board/ Tuition per Semester/Quarter $______________________

References / Mentor:

Name____________________________ Title________________ Phone (____)______________

Address_________________________________________________________________________

Name____________________________ Title________________ Phone (____)______________

Address_________________________________________________________________________

Name ____________________________ Title_______________ Phone (____)______________

Address _________________________________________________________________________

 

Academic Honors:

List any academic honors you have earned and /or been awarded while in college.

___________________________________            _________________________________

___________________________________            _________________________________

___________________________________            _________________________________

___________________________________            _________________________________

 

 

 

 

Memberships:

List memberships in organizations related to surveying including: student organizations, National or professional organizations, or professional achievements.

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

 

INSTITUTIONAL CERTIFICATION

 

To be completed by Department Head, Registrar, or other Institutional Officer

 

  I hereby state that I have reviewed this completed application and find it to be accurate to the best of my knowledge.  Specifically, I have reviewed the academic standing, grade point average, and other matters related to the educational standing of the herein named student.

 

  Printed Name _____________________________________________________________

 

  Title ____________________________________________________________________

  Address _________________________________________________________________

  City _____________________________ State ___________   Zip Code _______________

  Country __________________________  Phone _________________________________

  Email ___________________________________________________________________

 

DATE: __________________   SIGNATURE: _______________________________________

 

 

 

 

Briefly describe how you meet the outlined criteria for this award. (A full write-up of your project, copy of your paper, or other documentation should be attached to this application. The Museum of Surveying may ask for additional information, therefore early submittal is encouraged.)

 

 

 

 

 

 

 

 

 

 

The Museum of Surveying (MOS) anticipates that the sole use of the scholarship will be used for tuition payment. However, in some instances, subject to approval of the MOS, funds may be used for education-related expenses such as textbooks, required equipment and lab fees. If you anticipate using the scholarship for other than tuition, please list such uses along with a brief explanation:

 

 

 

 

 

 

 

 

By signing this application, the applicant acknowledges the following:

 

  • I understand that the Museum of Surveying requires that the sole use of the scholarship will be for tuition payment unless the MOS approves in writing use of the funds for specific education-related expenses.

  • I understand that the Museum of Surveying will pay the scholarship monies directly to the school and I will be responsible for providing payment instructions.

  • I further certify that all information contained within this application is complete and 

       accurate to the best of my knowledge.

 

   _________________________________              _____________________________________________

        Date                                                         Applicant Signature

 

 

 

Please mail entire completed application to:

 

MUSEUM OF SURVEYING

220 S. Museum Drive

Lansing, MI 48933