Applicant Information

Name:	_____________________________________
MSPE Member Number:	_____________________________________
Street Address:	_____________________________________
City, State ZIP:	_____________________________________
E-Mail Address:	_____________________________________
Telephone Number:	_____________________________________
University Attending:	_____________________________________
Student ID Number:	_____________________________________
Social Security Number:	_____________________________________
Local Newspaper and Address:	_____________________________________
	_____________________________________
US Citizen and Michigan Resident:	[ ] Yes        [ ] No
Sex:	[ ] Female     [ ] Male

Scholarship Information

Please consider me for the following scholarship(s):

[ ] Anthony C. Fortunski, P.E. Memorial Grant

[ ] Robert E. Folmsbee, P.E. Memorial Grant

[ ] McNamee, Porter & Seeley/U of M/John C. Seeley, P.E.
      Memorial Scholarship

[ ] Abrams Grant

[ ] MSPE Undesignated Grant

Permission to Release Information

By submitting this application, I authorize university officials or professors to make available to MSPE information concerning my academic record.

___________________________________________________    __________________
Applicant's Signature	Date

University Official/Professor/Faculty Advisor Certification

I hereby certify that the academic information and summary of activities as submitted in this application are correct and that the applicant meets the eligibility requirements as outlined.

____________________________________________    _________________________
Printed Name	Title
____________________________________________    _________________________
University/College	Phone Number
___________________________________________________    __________________
Applicant's Signature	Date

Please include a separate sheet of paper if necessary

Work Experience

List part-time and summer employment you have worked since entering college.

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Professional Activities & Memberships

List professional activity and membership involvements (other than jobs) you have participated in since entering college. Include MSPE Student Chapter activities.

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Activities

List your involvement in extracurricular activities (other than jobs) you have participated in since entering college.

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Honors

List any special honors and/or scholarships you have received since entering college.

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Send completed MSPE scholarship applications to:

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