INIA Scholarship Application Applicant's Name: _________________________________________ DOB: _____________ SSN: ________________ Address: _________________________________________________ Phone: ___________________________________ INIA Member's Name: ______________________________________ Status: active ______ deceased ______ Member's Address: ________________________________________ Member's Phone: ___________________________ Certification Statement: I certify that I monitored the writing of the attached essay. The applicant composed the essay in his/her own words without assistance from others. Assistance with typing only is permitted. Signature __________________________________ Relationship to applicant: ______________________ Forward the completed application, including essay to: INIA 4540 E. Collinwood Dr. Gilbert, AZ 85298-4009 E-mail: info@inia.org fax: 858.271.4407 tel: Toll Free: (888) 842-8432 Outside North America: 858.271.4407 Cumulative GPA: ________ GPA during last year: ________ List activities/clubs, school or community: _____________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Describe any past or current work experience, indicating whether paid or volunteer. Specify length of time spent at each. _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ List ant awards, special achievements, or scholarships (indicate value) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Essay All applicants must complete an essay of 500 words or less, describing his /her educational and career goals. If these specific goals have not yet been decided, general areas of interest and/or plans for the future should be addressed. Any other relevant information the applicant wished to be considered by the selection committee, such as financial hardship, should also be included. The certification statement regarding the completion of the essay, on the first page of the application, must be signed for the essay to be considered. If possible, essays should be submitted to INIA in typewritten form; however, legible hand-written submissions will be accepted.