Step 1 of 7 14% FacebookThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formParental ConsentI agree to the release of this information for the Governor’s Industrial Safety and Health Advisory Board’s consideration of this application. I further authorize the release of my child’s name and image (photographic or video) if selected to receive the scholarship, to the Board for educational and promotional purposes. Yes, I consent to the release of my child’s information No, I do not consent to the release my child’s information Applicant InformationName(Required) First Last Address(Required) Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email(Required) Phone(Required)Are you 18 or older?(Required) Yes No Education Background & PlanCurrent status(Required) High School Senior or completing GED Attending College, University, or Trade School Employed, continuing professional safety education Name of High SchoolCurrent EmployerAre you enrolled in a Head Start or Running Start program? Yes No Name of College, University or Trade SchoolWhat school or further education will you use the scholarship for?Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Is this a two year or four year institution? Two year Four year Will you receive an Associates of Art degree? Yes No When did you first attend this school?Have you been accepted as a full time student? Yes No When do you expect to know?Field of study – Major:Field of study – Minor: Additional InfomationSchool and Community ActivitiesPlease provide a summary description of any extracurricular activities which you have been involved with, your responsibilities as well as the duration of your participation.Honors and AwardsPlease list all honors and/or awards which you have received.Click the + to add additional entries. Add RemoveOffices and Positions of LeadershipPlease list all of the offices and/or positions of leadership which you have held.Click the + to add additional entries. Add Remove Employment HistoryList Jobs HeldInclude at least 5 years worth of employment or as many positions as you have held in the last 5 years or upload a resume as an attachment.Click the + to add additional entries.PositionResponsibilitiesFromTo Add RemoveResumeAttach resumeAccepted file types: doc, docx, pdf, Max. file size: 50 MB. Applicant EssayPlease provide 300 – 500 word essay outlining how you intend to further your occupational safety and health education and what you plan to do in the future to increase workplace safety & health. You may type your essay below or upload as an file attachment. Type EssayEssay UploadAccepted formats: doc | docx | pdfAccepted file types: doc, docs, pdf, txt, Max. file size: 50 MB. ReferencesThe application must include references from a Teacher or Professor, or your Employer, and one from another person in your Community. Optionally you may request a reference from a school Counselor or Advisor. Providing their name and email will allow them to see your name, your personal notes as entered below, and the scholarship name but no other information. Teacher/Professor/Employer Reference Name(Required) First Last Email(Required) Personal Note to Teacher/Professor/Employer(Required)No additional note provided.This field is hidden when viewing the formTeacher/Professor ReferenceCommunity Reference Name(Required) First Last Email(Required) Personal Note to Community ReferenceNo additional note provided.This field is hidden when viewing the formCommunity Reference(Required)Counselor/Advisor Reference Name First Last Email Personal Note to Counselor/AdvisorNo additional note provided.This field is hidden when viewing the formAdvisor/Counselor Reference CERTIFICATION AND RELEASE AUTHORIZATION(Required)I certify that the information contained in this application is true, complete and accurate; I authorize release of any of this information to confirm and/or verify this application. I further authorize the release of my name and image (photographic or video) to the scholarship grantor for educational and promotional purposes. I certify this submission is accurate and consent to release of name and image.Parental ConsentSince you are under 18, you must provide the name and email address of a parent or guardian to provide consent. They will be able to view your application and submit their consent.Parent Name First Last Parent Email
