Included in this form:

• Application

• Work Experience

• References

• Essay

Full name_____________________________________ Date of birth______________________

Address__________________________________ Phone_______________________________

City__________________________________ State________________ Zip________________

Current College_________________________________________________________________

School Address_____________________ City_______________ State_____ Zip_____________

College Cumulative G.P.A._____________ 

Number and ages of brothers_________________________ Sisters________________________

Marital Status___________________________ Number and ages of children_________________

Name of College/Police training academy you plan to attend________________________________

_____________________________________________________________________________

Have you applied for admission?___________________ Have you been accepted?_____________

List clubs, sports, activities, etc. that you are active in high school and college. Explain your role or 

duties in these extracurricular activities.

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

List any volunteer or non-school activities in which you are involved and your role in them:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Employer_________________________________ Supervisor___________________________

Address______________________________ City______________ State_____ Zip__________

Phone________________ Date employed from__________________ To___________________

Nature of work_________________________________________________________________

_____________________________________________________________________________

Employer_________________________________ Supervisor____________________________

Address______________________________ City______________ State_____ Zip__________

Phone________________ Date employed from__________________ To___________________

Nature of work_________________________________________________________________

_____________________________________________________________________________

Employer_________________________________ Supervisor____________________________

Address______________________________ City______________ State_____ Zip__________

Phone________________ Date employed from__________________ To___________________

Nature of work_________________________________________________________________

_____________________________________________________________________________

Other work experiences or job training_______________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Have you applied for a PELL grant?__________ If no, why not?__________________________

_____________________________________________________________________________

Have you applied for a Michigan Works Grant?__________ If no, why not?__________________

_____________________________________________________________________________

Have you applied for any student loans or work study programs?__________ If no, why not?_____

______________________________________________________________________________

______________________________________________________________________________

REFERENCES: List two adults, who are unrelated to you, who agree to serve as references to provide information to the selection committee concerning your character, ability, honesty, and potential to make the best use of this scholarship.

Name_________________________________ Occupation______________________________

Address__________________________________________ Phone_______________________

City___________________________________ State___________ Zip____________________

Name_________________________________ Occupation______________________________

Address__________________________________________ Phone_______________________

City___________________________________ State___________ Zip____________________

*Enclose with this application one letter of reference from a teacher, counselor, or administrator from

your current school or college.

*Enclose with this application an  official transcript/transcripts ,  indicating your accumulative grade point average.

To the best of my knowledge, all information reported in this application is complete and correct. 

I further agree to attend an interview, if requested by the scholarship committee.

_______________________________________________________  _____________________

Signature of Applicant                                                                                Date

ALL APPLICATIONS SUBMITTED FOR CONSIDERATION WILL BE DESTROYED AFTER SELECTION PROCESS IS COMPLETED AND NONE WILL BE RETURNED.

Essay

IN THE SPACE BELOW DESCRIBE IN YOUR OWN WORDS YOUR CAREER OBJECTIVE IN LAW ENFORCEMENT OR CRIMINAL JUSTICE… INCLUDE YOUR PROPOSED GOALS, AND ANY ACTIVITIES OR STUDIES IN LAW ENFORCEMENT. THIS IS YOUR PAGE… YOU MAY ADD ANY INFORMATION THAT YOU FEEL IS IMPORTANT IN EVALUATING YOUR SCHOLARSHIP APPLICATION. (YOU MAY USE THE BACK OF THIS PAGE IF NEEDED)