EPG Scholarship Application

To be eligible for a scholarship, the applicant must be sponsored by a bonafide member of the Energy Polymer Group, so defined as a dues paying member in good standing for at least one year and one who has attended at least one meeting during the year.

Energy Polymer Group members are also eligible for the scholarships if all conditions are met.

Applications must be received by the Scholarship Chairperson no later than March 1. In addition to the application form below, applicants must also submit, by certified mail, Social Security number, required transcripts, two letters of recommendation (from applicant sponsor and educational instructor), and any other information useful to the selection process. Any applications (including information sent by mail) received after March 1 cannot be considered. Scholarship awards will be announced at the Spring meeting of the EPG.

If you have any questions about how to respond to any questions on this application, we suggest that you contact your EPG Sponsor for help. If he or she is unable to provide answers, please contact Julie Johnson, EPG Scholarship Chairperson via email at julie@fluororecovery.com.

We encourage all potential applicants to closely read the above criteria in order to prevent any unnecessary delays in processing the applications.

Answer all questions that apply to you. Fields with * must be answered by ALL applicants!

Scholarship Applied For:*   

1) This Application Is For Academic Year (yyyy):*

    Semester:*   

2) First Name:*   Middle Initial:   Last Name:*

3) Student Address(Complete only if you are a student living away from home):
   






4) Home Address:*
   






5) Phone Number:*

6) Social Security Number:
YOU MUST INCLUDE YOUR SOCIAL SECURITY NUMBER WITH YOUR MAILED INFORMATION

7) Energy Polymer Group Sponsor:*

8) Applicant's Email Address:*  

9) EPG Sponsor's Email:*  

10) College Classification (period you are applying for):*

11) Major:*   Minor:*
(If you are just starting college, enter the major and minor you intend to declare.)

12 ) Graduation Date: High School (yyyy):*   
                                                College (yyyy):
(If you are still in high school, enter the year you will graduate.)

13) Cumulative High School G.P.A.:*  Scale Used: *
(If you have not yet graduated, enter 'NA' in Rank and Number of Students.)
Rank In Graduating Class:*           Number of Students In Class

Composite Score:*

14) Transfer Students (submit transcripts)
Cumulative G.P.A.:               Scale Used: 
Semester Hours Earned:      Semester Completed:

15) Currently Enrolled Students (submit most current grade report)
Cumulative G.P.A.:               Scale Used: 
Semester Hours Earned:      Semester Completed:

16) Work Experience:*

17) Major Activities Participated In (give details, office held, etc.):*

18) Major Awards and Honors Received:*

19) Career Objectives:*

20) Other grants or scholarships and amounts you have been awarded for the year:*

PLEASE, CAREFULLY CHECK THE INFORMATION
ON THIS FORM BEFORE YOU SUBMIT IT!

By submitting this form, you certify that all of the information on this form is true and complete to the best of your knowledge. If asked by an authorized official, you agree to provide proof of the information that you have given on this form.

When submitted, this form will be emailed to the Committe Chairperson, your EPG sponsor, and back to you for your records.

To insure the processing of your application, be sure you send, by certified mail, the required documentation (social security number, transcripts, and grade reports) to:
Julie Johnson
Specialty Elastomer Recovery, Inc.
P. O. Box 820371
Vicksburg MS 39182

This form and the required documentation must be received by March 1 in order to be considered.

Please click the "Submit" one time only. It may take several seconds to process your application.