Scholarshipapp

Completed applications and forms must be post marked by June 2, 2008 and returned to

This scholarship is available only to children or employees of eligible MPCA member firms.

NOTE: In order for an application to be considered, at least one item in each section must be checked.

____ I am a natural, adopted, legal guardian child, or member of household of a person who has worked full time a minimum of four (4) years for an active member firm in good standing for at least three (3) years.

____I am an employee of a pest control company who has worked full time a minimum of four (4) years for an active member firm in good standing for at least three (3) years who will enter or attend college full-time.

____ I have been accepted as a full-time student by an accredited college/university.

____ I am currently a full-time student in an accredited college/university.

I certify that the above information is true and correct.

Student's Signature______________________________________ Date________________________

Student's Full Name _________________________________________________________________

Home Address _______________________________________________________________________

Home Phone: ________________________________ Social Security No.________________________

Date of Birth: __________________________ Age____________ U.S. Citizen ______Yes ______No

Name: ______________________________________________________________________________

City, State & Zip: _____________________________________________________________________

Year of graduation: _______________ Rank in class: _________________ Class size: ____________

Grade point average: ______________ Combined SAT score: ____________________

Extra curricular activities (Include athletic and non athletic, leadership roles, etc)

___________________________________________________________________________________

____________________________________________________________________________________

Awards: ____________________________________________________________________________

___________________________________________________________________________________

Community activities:_________________________________________________________________

____________________________________________________________________________________

Future goals:_________________________________________________________________________

____________________________________________________________________________________

Copy of college acceptance letter attached ______ or currently attending college full-time _______

College presently attending: ____________________________________________________________

City and State: ______________________________ Major Field: ______________________________

What year of study: _______________ GPA: ___________________

Have you ever been suspended from school/college for disciplinary reasons? _______________

Have you ever been convicted or pleaded guilty to a felony? _______________

If either answer is "Yes", include and explanation in "Remarks" section.

References: (High School teacher, Principal, and/or Non-Relative)

Name: _______________________________ Name: __________________________________

Position: _____________________________ Position: ________________________________

Address: _____________________________ Address: ________________________________

City _________________________________ City ____________________________________

State, Zip_____________________________ State, Zip________________________________

Phone: _______________________________ Phone: _________________________________

Applicant's Employer: _________________________________________________________________

Address: ____________________________________________________________________________

Phone: ___________________________ Immediate Supervisor: ______________________________

Company ________________________________ Company: __________________________________

Address: _________________________________ Address: ___________________________________

_______________________________________ ___________________________________________

Dates Employed: ________________________ Dates Employed: _________________________

Name of parent or guardian_____________________________________________________________

Address: ____________________________________________________________________________

Employer: ___________________________________________________________________________

Address: ____________________________________________________________________________

Position: ____________________________________________________________________________

Name of Company: ___________________________________________________________________

Member in good standing of MPCA for a minimum of 4 years Yes _____No ________

Company Representative Name: ____________________________________________

Position: _______________________________________________________________

Signature: __________________________________________ Date: _____________

On plain paper, type a 500 word essay on how your course of study will enrich the fabric of our society. Do not use an essay previously submitted. Include your last name within the top 3/4" of the paper. Number the pages if more than one page is necessary. Enclose with your application.



	Code # Maryland State Pest Control Association Doug Sroka Memorial Scholarship Qualifications of Scholarship Recipients Completed applications and forms must be post marked by June 2, 2008 and returned to MPCA Sroka Scholarship P. O. Box 117 Marydel, MD 21649-0117 This scholarship is available only to children or employees of eligible MPCA member firms. NOTE: In order for an application to be considered, at least one item in each section must be checked. Section 1 ____ I am a natural, adopted, legal guardian child, or member of household of a person who has worked full time a minimum of four (4) years for an active member firm in good standing for at least three (3) years. ____I am an employee of a pest control company who has worked full time a minimum of four (4) years for an active member firm in good standing for at least three (3) years who will enter or attend college full-time. Section 2 ____A citizen of the United States Section 3 ____ I have been accepted as a full-time student by an accredited college/university. ____ I am currently a full-time student in an accredited college/university. Section 4 ____ I have at least one of the following: A. "B" high school grade average B GED equivalent C Minimum of 900 SAT score D Minimum of 2.8 college GPA I certify that the above information is true and correct. Student's Signature______________________________________ Date________________________ Type or Print Student's Full Name _________________________________________________________________ Home Address _______________________________________________________________________ Home Phone: ________________________________ Social Security No.________________________ Date of Birth: __________________________ Age____________ U.S. Citizen ______Yes ______No High School(s) Attended: Name: ______________________________________________________________________________ City, State & Zip: _____________________________________________________________________ Year of graduation: _______________ Rank in class: _________________ Class size: ____________ Grade point average: ______________ Combined SAT score: ____________________ Extra curricular activities (Include athletic and non athletic, leadership roles, etc) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (If additional space is needed, use "Remarks" section) Awards: ____________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Community activities:_________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Future goals:_________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Copy of college acceptance letter attached ______ or currently attending college full-time _______ College presently attending: ____________________________________________________________ City and State: ______________________________ Major Field: ______________________________ What year of study: _______________ GPA: ___________________ Have you ever been suspended from school/college for disciplinary reasons? _______________ Have you ever been convicted or pleaded guilty to a felony? _______________ If either answer is "Yes", include and explanation in "Remarks" section. References: (High School teacher, Principal, and/or Non-Relative) Name: _______________________________ Name: __________________________________ Position: _____________________________ Position: ________________________________ Address: _____________________________ Address: ________________________________ City _________________________________ City ____________________________________ State, Zip_____________________________ State, Zip________________________________ Phone: _______________________________ Phone: _________________________________ Applicant's Employer: _________________________________________________________________ Address: ____________________________________________________________________________ Phone: ___________________________ Immediate Supervisor: ______________________________ Previous Pest Control Industry Employment if any: Company ________________________________ Company: __________________________________ Address: _________________________________ Address: ___________________________________ _______________________________________ ___________________________________________ Dates Employed: ________________________ Dates Employed: _________________________ Parent or Guardian Info Section Name of parent or guardian_____________________________________________________________ Address: ____________________________________________________________________________ Phone: _________________________________ Employer: ___________________________________________________________________________ Address: ____________________________________________________________________________ Phone: _________________________________ Number of years with present employer: ________________ Position: ____________________________________________________________________________ Remarks: Sponsoring Pest Management Professional Name of Company: ___________________________________________________________________ MDA Business License #: _______________________________ Member in good standing of MPCA for a minimum of 4 years Yes _____No ________ Company Representative Name: ____________________________________________ Position: _______________________________________________________________ Signature: __________________________________________ Date: _____________ Essay Requirement On plain paper, type a 500 word essay on how your course of study will enrich the fabric of our society. Do not use an essay previously submitted. Include your last name within the top 3/4" of the paper. Number the pages if more than one page is necessary. Enclose with your application.