The Delta Kappa Gamma Society International

Scholarship Award
Sponsored by

Beta Omicron Chapter

Chi State

This scholarship is designed to aid mature men and women who are entering or
returning to college to earn a degree and/or credential in the field of education
Delta Kappa Gamma is an International Society whose mission is to promote
professional and personal growth of educators and excellence in education.

INSTRUCTIONS
Please complete this application as thoroughly as possible and return it with completed references to
the designated address at the bottom of page 4 before the deadline of May 15, of the current year.
Before you begin this application, please be sure that you meet the Scholarship Award criteria listed
below.
1. The applicant shows characteristics of maturity in that he or she is motivated to improve
his/her skills and qualifications in order to earn a teaching credential or an advanced
degree in the field of education.
2. The applicant shows financial need.
3. The applicant is currently enrolled in a community or four year college with the stated goal
of earning an educational degree. (Must have proof of registration.)

Application should be typed or printed neatly in ink.

Part I. PERSONAL DATA

Name ____________________________________________________________________________
(last)
(first)
(middle)
Mailing Address ____________________________________________________________________
(number and street)
City _______________________________Zip Code _______________________________________
Area Code/Telephone _____________________ Social Security No. __________________________
Marital Status ________________________________
Number of Dependents (if any) ___________
Relationship (if dependents are children, please list their ages) _______________________________
_________________________________________________________________________________
*********************************************************************************
Part II. Occupational Experience
List your most recent employment first and any work experience that directly relates to, or may have
helped prepare you for your career goal.
Employer ______________________________ Address ___________________________________
Dates of Employment _________________________ Salary _______________________________
Responsibilities ____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Employer ______________________________ Address ___________________________________
Dates of Employment _________________________ Salary _______________________________
Responsibilities ____________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
**********************************************************************************
Part III. EDUCATION AND OTHER EXPERIENCE
List schools attended and any in which you are currently enrolled. Remember to include any training
you have received that helped you prepare you for your career goal.
School

Location

Dates Attended

Field of Study

Degree

**********************************************************************************
PART IV. GOALS
1. Name of institution in which you are enrolled or plan to enroll in:
_______________________________________________________________________________
2. Approximate period of study (months/years) needed to accomplish your
educational goal:
From ______________________________ to _________________________________________
3. Please list the degree and/or credential you are currently seeking:
______________________________________________________________________________
*********************************************************************************
PART V. PERSONAL STATEMENT
Why do you feel you would make a suitable scholarship recipient describe your career goals, address
the criteria for this program and any adverse conditions you have overcome. Please note any
educational achievements (grants, awards), current grade point average, committees you may have
worked on. Only cite examples of recent accomplishments (within the last five years at most)
Use a separate sheet of paper to respond. Your answer should not exceed one typewritten page.
*********************************************************************************
PART VI. FINANCES
It is important that this section reflect a tune picture of your financial need. In the gross annual
income section, please report all amounts in annual/yearly figures (monthly x 12).
Annual Family Income
1. Gross annual income:
Source
Amount
*Applicant _______________I___________________________I_____________________
*Spouse _________________I___________________________I_____________________
*Other Household Members _I___________________________I_____________________
TOTAL GROSS INCOME __I___________________________I_____________________
2. Savings available for school _____I___________________________I_____________________
3. Loans/Scholarships ____________I___________________________I_____________________
4. Other (benefits, child support, alimony, etc.) ____________________I____________________
5. Applicants education expenses. Transportations refers to either public transporttation expenses when going to school, and /or cost of gas, parking and car maintenance.
Tuition ______________ Books ________________ Transportation ____________________
Other (describe) ______________________________________________________________
____________________________________________________________________________

PART VII. REFERENCES

Use the attached Personal Reference form; submit TWO references from people who are not related
to you along with your completed application. References must be sent with your completed
application.
**********************************************************************************
PART VIII. AGREEMENT
I understand that my application and supporting information becomes the property of The Delta
Kappa Gamma Society International, Beta Omicron Chapter of Chi State, and they shave have
discretionary authority in all matters pertaining to this award.
L
The completed application, including references, must be received by May 15 of current year.
I understand that this award is taxable.
I certify that the information in this application is complete and accurate to the best of my knowledge,
and I will notify Beta Omicron Chapter if there are any significant changes.
Signature of Applicant ______________________________________ Date ____________________
Nominated by (DKG member) ________________________________________________________
**********************************************************************************

APPLICANT: Retain this address for future reference.

Send completed application to:
The Delta Kappa Gamma Society International, Beta Omicron Chapter
Attention: Marlene Vest
19003 Wiersma Ave.
Cerritos, CA 90703
Phone: (562) 860-5970
REMINDER: In order to be considered for this scholarship, Beta Omicron must
Personal Reference
receive the completed application (including references) by May 15 of current year.

For A Scholarship Award Candidate

Personal Reference
For A Scholarship Award Candidate
Thank you for taking your time to recommend __________________________________________
for consideration as a Delta Kappa Gamma Scholarship Award candidate. Criteria for selection for
this award are printed on the reverse side of this form. Please use your personal knowledge of this
candidate to respond to the following questions.
1. How long have you known the candidate and in what capacity (instructor, friend, co-worker,
employer, etc)?

2. What is your personal knowledge of the candidates strengths/responsibilities in his/her life?

(Address specific examples of accomplishments at work, school, home, community, place of
worship, etc.)?

3. What is your personal knowledge of the candidates educational goals and her/his progress
toward accomplishing these goals? (Consider any barriers/difficulties this person has
overcome.)

4. Is there any additional information you would like to mention that you think the judges
should know about the candidate?

Name ______________________________________________________ Date _________________

Address __________________________________________________________________________
Telephone ________________________________________________________________________
Please return the completed reference to the applicant for submission with the application.
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CRITERIA FOR SELECTION OF SCHOLARSHIP AWARD RECIPIENTS

This award is designed to assist mature men and women who are entering or returning to college to
pursue a degree/credential in the field of education.
The recommended guidelines for choosing a recipient will include the following criteria:
1. The applicant shows characteristics of maturity in that he/she:
a. Can adapt to new situations;
b. Is motivated to improve;
c. Can accept responsibility;
d. Is committed to entering the field of education.
2. The applicant clearly indicates that college level training is necessary to reach his/her
educational goal.
3. The applicant demonstrates financial need.

Purpose #5

Revised: 3-1-12
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