Name:                                                                                  Social Security #:

Local Address:

Local Telephone Number:

CLASS STATUS:  To be eligible, a student must have completed at least 90 hours by the end of the current spring semester with an overall Q.P.A. above 2.50.  Students must also have completed 12 hours in Psychology (6 or more of which must have been earned at Clarion University).  Restriction:  A person may only receive this award once.

         Total number of hours earned by end of this spring semester:

         Total number of hours earned in Psychology by end of this spring semester:

         Number of hours in Psychology earned at CUP by end of this spring semester:

         Overall Q.P.A. in college courses taken at CUP:
 

PLEASE DESCRIBE YOUR SERVICE TO THE FIELD OF PSYCHOLOGY:
 
 
 
 
 
 
 
 
 
 
 

PLEASE DESCRIBE YOUR SERVICE TO CLARION UNIVERSITY:
 
 
 
 
 
 
 
 

PLEASE DESCRIBE YOUR SERVICE TO OTHER STUDENTS:
 
 
 
 
 
 
 
 
 
 
 

PLEASE DESCRIBE THE SERVICE YOU HAVE GIVEN TO YOUR COMMUNITY:
 
 
 
 
 
 
 
 
 
 
 

OTHER RELEVANT INFORMATION:
Please describe any other service contributions you may have made which do not fit into the above
four categories.
 
 
 
 
 
 
 
 
 
 

SUPPORTING REFERENCES:
I authorize the committee to contact any of my instructors, employers, or student co-workers listed
below in order to clarify or confirm statements made by me.  (Please be sure to include the person's title and phone number.)  I also authorize the Scholarship Committee to view my transcripts.

Signature:                                                       Date:
                    (Authorization)

Reference:                                                                         Telephone #:

Reference:                                                                         Telephone #:
 

Please leave this application with the Psychology Department secretary, Rm. 237 Harvey Hall, by the last Friday in March.  Attach additional sheets if necessary.  To be eligible for this award, which is to be granted in the fall, you must be enrolled as a full-time student at that time.