Joseph F. Salino Memorial Scholarship Application
Date (PPMA) Received
__________________
Applicant’s Full Name:
____________________________________________________________________________________
Home Phone.
____________________________________________Social Security
No.________________________________
Date of Birth:________________________Age
____________U.S. Citizen___________Yes ____________No______________
High School (s) Attended:
_____________________________________________Phone:_______________________________
City and
State__________________________________________________________________________________________
Year of Graduation
_________________________Rank In Class_______________________Totai # in
Class________________
Grade Point
Average:__________________________________Combined SAT
Score:_________________________________
College Presently
Attending:_______________________________________________________________________________
City and State:
___________________________________________Year of
Graduation_______________________________
Have you ever been suspended from
school/college for disciplinary reasons?
[ ]
Yes [ ] No
Have you ever been convicted of or pleaded
guilty to a felony? [ ]
Yes [ ] No
if you have answered Yes to either
questions, include explanation in "Remarks" section,
Applicant's Employer
_____________________________________________________________________________________
Address:
______________________________________________________________________________________________
Phone:
______________________________________Immediate
Supervisor_________________________________________
Previous pest management
industry employment
Company:
________________________________________ Company
___________________________________________
Address:__________________________________________ Address
_____________________________________________
From:__________________
To:___________________ From:__________________ To:___________________
Name of parent/guardian
_______________________________________Phone:
____________________________________
Address:
_______________________________________________________________________________________________
Employer:_____________________________________________________Phone:
____________________________________
Address:
_______________________________________________________________________________________________
Number of years with present employer:
________________Position__________________________________________________
Remarks: Use this space, and additional
pages as needed, to explain/expand upon any earlier items.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Applicant's Signature
_____________________________________________Phone____________________________________
Sponsoring Company:
_________________________________PA Business Lie.
#_______________________________________
Member in good standing of PPMA for minimum
of 4 years [ ]
Yes [ ] No
Licensed PMP's Name (Print)
_________________________________________________________________________________
PA Certification
#_________________________________________________________________________________________
PMP's Signature
__________________________________________________Date____________________________________
