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Application

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									THE PETERSON SCHOLARSHIP FUND SCHOLARSHIP APPLICATION FORM


Name __________________________________________________________________

Facility _________________________________________________________________

Mailing address:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________

Phone: _________________________________________________________________

Immediate supervisor or manager and their contact information:____________________

_______________________________________________________________________

This application is for:

      Myself
      One of my staff     (Name/Position): ____________________________________

This application is for:

      Attending the WSSHE Annual Conference
      Attending the WSSHE Semi-Annual Conference
      Attending a conference, educational course, seminar, or other class(es)

Please list the reason why you are requesting this fund. If you are requesting the fund for
anything other than to attend the Annual/Semi-Annual Conference, please give the
class/seminar/course name, location, and a brief description:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
For PPSF Board Use Only:

APPROVED                      DISAPPROVED




2/23/2012

								
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