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Electronic Treasurers Final Event Report

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Roy W. Likins Scholarship
 
Application Form
 
Please note that completion of the form below does not constitute the entire application. Supplementary documentation as specified on the Information Page must also be submitted by the deadline. The application, including all required documentation, must be postmarked no later than midnight, May 1st of each year.
 
Submit Documentation To:
 

Bill Young
c/o St. Johns County
1205 State Road 16
St. Augustine, FL 32084
Phone: (904) 209-2703
 Email: byoung@co.st-johns.fl.us
 

 
 
 1.   Full Name of Applicant:  
    Age:  
    School Street Address:  
    School City, State & Zip::  
    School Telephone Number:          
    Home Address:  
    Home City, State, & Zip:  
    Home Telephone Number:
 
    
 2.    College 1:
 
    Attended Date From:   To: 
    Program of Study:
 
    College 2:
    Attended Date From:   To: 
    Program of Study:
 3.  
Involvement in drinking water industry related technical activities.
    Name of Activity:
    Contribution or Office Held:
    Date:
 4.   Involvement in non-technical civil and community activities.
    Name of Activity:  
    Contribution or Office Held:  
    Date:  
5.   Special recognition and academic honors.
    Name of Recognition:  
    Reason Awarded:  
    Date:  
 6.   Employment while attending college.
    Employer 1:  
    Job Description:  
    Average Hours/Week:  
    From Date:   To: 
    Employer 2:  
    Job Description:  
    Average Hours/Week:  
    From Date:   To: 
 7.   Applicant's Certification and Permission to Release Information.
   
  • I hereby certify that all information submitted on this application is true and accurate to the best of my knowledge. I understand that submitting non-factual information will automatically disqualify me from any consideration for a scholarship.
  • By submitting this application, I authorize my college(s) records office to make available to the Florida Section AWWA information concerning my academic records.
  • I hereby grant permission to allow FSAWWA to release information contained herein to other potential sources of scholarship assistance for my studies.
    Yes   No
         
       
 
 
 
 
 
 
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