THE SAM HOUSTON WATER UTILITIES ASSOCIATION
A TEXAS WATER UTILITIES ASSOCIATION AFFILITATE
TO BE COMPLETED BY ACTIVE MEMBER:
Member Name Social Security Number
Relationship to Applicant Years Member
Present Employer Years Employed
Address Phone Number
Present Position
Signature Printed Name Date
TO BE FILLED OUT BY APPLICANT:
Name of Applicant Address
Phone Number
Age Date of Birth Place of birth
EDUCATIONAL DATA:
High School Attended Year Graduated
Grade Point Average out of Class Ranking
(Furnish copies of High School transcript with Application.)
Please show any of the following activities that may apply:
Scholastic Honors Class Officer
High School Organizations/Athletics
Extra Curricular Activities (Scouts, etc.)
Post Graduate Schooling Years Attended
Commercial / Trade Schools attended
If employed during school or vacation period, please list:
1.) Employer Address
Phone Number
Type of Employment Income Year
2.) Employer Address
Phone Number
Type of Employment Income Year
Character References:
Name Address
Phone Number
Name Address
Phone Number
Name Address
Phone Number
Additional Information:
a. Should you receive the award, what research or course of study do you plan to pursue? Briefly describe:
.
b. How long do you believe it will take you to accomplish this work?
.
If I am selected as a recipient of the Sam Houston Water Utilities Association Award, I agree to initiate the work within the scholastic year. I further agree to send grades to the Executive Committee at the end of the first semester. If the cash award is not used within the time established by the Executive Committee, it will be returned to the Sam Houston Water Utilities Association. I also agree to attend a monthly meeting held by the Sam Houston Water Utilities Association.
Signature Printed Name Date
TO BE FILLED OUT BY PARENT OR GUARDIAN (IF APPLICABLE):
Name Address
Phone Number
Relationship to Applicant
Number of household members___________________________Total Family Income_______________
Signature Printed Name Date
Please send application and all pertinent supporting documents to:
Sam Houston Water Utilities Association
C/O Maria M. Mendoza, HCPHES
P.O. Box 690008
For internal use only:
Date Application received:
Action by Scholarship Committee:
Date of Scholarship Committee Review:
Committee Members:
Chairman Member
Member Member Member