Applicant Information

Name:	_____________________________________
Name of MSPE member parent (if applicable):	_____________________________________
Street Address:	_____________________________________
City, State ZIP:	_____________________________________
E-Mail Address: (if applicable)	_____________________________________
Telephone Number:	_____________________________________
Social Security Number:	_____________________________________
Local Newspaper and Address:	_____________________________________
	_____________________________________
US Citizen and Michigan Resident:	[ ] Yes        [ ] No
Sex:	[ ] Female     [ ] Male
Did you participate in MATHCOUNTS?	[ ] Yes        [ ] No

College Preferences

List two Michigan ABET accredited universities to which you have applied (scholarships will be granted to first preference school choice

First Choice:	_____________________________________
Date Applied:	______________________
Have you been accepted?	[ ] Yes        [ ] No
Second Choice:	_____________________________________
Date Applied:	______________________
Have you been accepted?	[ ] Yes        [ ] No

Activities and Honors

Please include a separate sheet of paper if necessary

List technical activities sponsored by high school, ie: JETS, Math Club, Science Fair, etc.) Include school years you were involved (ie: junior, senior) and any offices you held.

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List non-technical activities sponsored by high school, ie: band, cheerleading, student government, etc.) Include school years you were involved (ie: junior, senior) and any leadership positions you held.

_________________________________________________________

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List academic honors or special achievements, ie: National Honor Society, Science Fair, Westinghouse Talent Search, etc. Include the school year in which you were honored (junior, sophomore) and a description of what you did to earn that honor.

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List paid employment you held for three weeks or more during your high school career, September-May. List number of weeks per school year worked, and average hours worked per week. Include the school year in which you worked, ie: junior, sophomore

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List summer activities (ie: paid employment, university programs, involvement in Boy's/Girl's State, etc) Include the school year after which this summer activity took place, ie: junior, sophomore, number of weeks each summer, and average hours involved per week.

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Organized volunteer, community or other activity not sponsored by high school (ie: sports, Scouts, 4-h, candy striper, Big Brothers/Big Sisters, etc.) Include the school year in which you volunteered, ie: junior, sophomore, average hours per week, and list significant contributions you made.

_________________________________________________________

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_________________________________________________________

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Have your counselor or principal verify the application and attachments, and both of you sign below. Then send attachments and application to your local chapter chair before the deadline: the second Monday in January.

Counselor/Principal Certification

I hereby certify that the academic information and summary of school activities on this application are correct, and to the best of my knowledge, the applicant has applied for admission to the schools listed.

Average G.P.A. for the the 10th and 11th grades:	______________________
ACT composite score: (minimum 26 required)	______________________

Transcript showing ACT score and GPA are attached to this application:	[ ] Yes        [ ] No
12th Grade 1st Semester Course List is attached to this application:	[ ] Yes        [ ] No
Applicant meets all academic requirements to be eligible (as described in the document provided by the student):	[ ] Yes        [ ] No

Printed Name:	_____________________________________
High School:	_____________________________________
Street Address:	_____________________________________
City, State ZIP:	_____________________________________
Telephone Number:	_____________________________________
Fax Number:	_____________________________________

___________________________________________________    __________________
Counselor/Principal Signature	Date

Permission to Release Information

By submitting this application, I authorize my high school counselor/principal to provide information concerning my academic records to MSPE. I hereby grant premission to MSPE to release information contained herein to other potential sources of scholarship assistance for engineering studies. I certify all statements contained herein are true.

___________________________________________________    __________________
Applicant's Signature	Date

Send completed MSPE scholarship applications to:

Michigan Society of Professional Engineers
PO Box 15276
Lansing, MI 48901-5276