SOUTH CAROLINA EMS SCHOLARSHIP APPLICATION

PLEASE TYPE OR PRINT CLEARLY

 

DATE OF APPLICATION - ______________________________

NAME - ___________________________________________________ MIDDLE INT-_______
Last First

MAILING ADDRESS -__________________________________________________________

CITY-_________________________________ STATE-__________ ZIP-__________________

TELEPHONE NUMBER - (HOME)-_(________)_____________________________________

(WORK)-_(________)_____________________________________

(PAGER) _(_______)_________________

EMAIL - ____________________________@________________________________________

NAME OF NEAREST RELATIVE - _______________________________________________

ADDRESS-___________________________________________________________________
CITY-__________________________________ STATE-__________ ZIP-_________________

TELEPHONE NUMBER - (_________)_____________________________________________

EMPLOYMENT HISTORY (past five years)

CURRENT EMPLOYER - _______________________________________________________

ADDRESS-___________________________________________________________________
CITY-__________________________________ STATE-__________ ZIP-_________________

IMMEDIATE SUPERVISOR-_____________________________________________________

TELEPHONE NUMBER - (_________)_____________________________________________

EMPLOYED FROM (DATE) ____________________ TO _____________________

EMPLOYER - _________________________________________________________________

ADDRESS-___________________________________________________________________
CITY-__________________________________ STATE-__________ ZIP-_________________

IMMEDIATE SUPERVISOR-_____________________________________________________

TELEPHONE NUMBER - (_________)_____________________________________________

EMPLOYED FROM (DATE) ____________________ TO _____________________

EMPLOYER - _________________________________________________________________

ADDRESS-___________________________________________________________________
CITY-__________________________________ STATE-__________ ZIP-_________________

IMMEDIATE SUPERVISOR-_____________________________________________________

TELEPHONE NUMBER - (_________)_____________________________________________

EMPLOYED FROM (DATE) ____________________ TO _____________________

Please use blank paper to continue if needed

EDUCATIONAL BACKGROUND

High School attended -_________________________________________ State-_____________

Diploma - Yes_________Date__________ No-_________ GED_________Date_______

Junior College - ______________________________________________ State-____________

Degree - Yes_________Date__________ program-__________________ No-____________

If no, do you plan to go back and finish? - Yes No

University-____________________________________________________ State-___________

Degree- Yes____________ Date____________ major-________________ No-_____________

If no, do you plan to go back and finish? Yes No

Please include copies of diplomas and/or degrees

Please list any other educational courses and/or certifications you may have. Please put "I" next to any that you have obtained instructor status in.

____________________________________ ____________________________________

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____________________________________ ____________________________________

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FINANCIAL INFORMATION

(Please note that the information gathered here will remain strictly confidential and will not be shared with anyone outside of the scholarship committee).

ANNUAL SALARY - 1999-_______________ 1998-_________________ 1997-____________

Please provide copies of W2 or tax information)

primary source of income for 1999-_________________________________________________

Checking account Yes No Average Balance - ___________________
(Circle one)
Savings account - Yes No Average Balance-____________________

Financial Institution - __________________________________________________________

City - ___________________________________ State-________________

I currently Rent Own (Circle one)

___________________________________________ BALANCE-____________________
NAME OF MORTGAGE COMPANY / LANDLORD

ADDRESS - _____________________________________________TEL # - _______________

AUTOMOBILE - _______ ___________ ______________ _________________
YEAR MAKE MODEL MILEAGE

FINANCED BY - ________________________________________TEL #__________________

BALANCE - $________________ MONTHLY PAYMENTS-$___________________

LOANS (OTHER) (credit card, personal loan, ect)

TYPE-_____________________ COMPANY____________________BALANCE-___________

TYPE-_____________________ COMPANY____________________BALANCE-___________
(please use additional paper if necessary).

Is there additional income you wish to include? YES NO
SOURCE OF INCOME-________________________________ AMOUNT-$_______________
MONTHLY ANNUALLY
NOTE- You do not have to include child custody, alimony of other information you do not wish to divulge.

HAVE YOU EVER BEEN CONVICTED BY A COURT OF LAW FOR ANY OFFENSE?

Yes-______________ No-______________

If answer is yes, please explain on separate piece of paper. Include date of conviction with explanation. Confirmation of a conviction does not necessarily eliminate you from receiving this scholarship.

1. What school do you plan to use this scholarship for?

EMT EMT-I PARAMEDIC

2. Where do you plan to attend to complete this school?____________________________________________

Approx start date of course-___________________

3. What are your plans once you complete this course? ___________________________________________________

_____________________________________________________________________________________________

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4. What interested you in the EMS field?______________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

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5. If you had complete freedom of choice (money and/or education aside) to choose any career, would that career be and why?

_____________________________________________________________________________________________

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4. In 500 words or less, please tell the committee why you deserve this scholarship:

(Please use separate paper if needed)