Scholarship Application Date of Application
4701 Market St., Suite H Fredericksburg, VA 22408 540-479-3021
Scholarship Application Date of Application:_____________
NAME:________________________________________________________________________ ADDRESS:_____________________________________________________________________ ______________________________________________________________________________ PHONE (C):_________________________ PHONE (H):__________________________________ CURRENT EMPLOYER:_____________________
PHONE:___________________
ADDRESS:________________________________ POSITION:_________________ ________________________________________
DATE EMPLOYED:____________________
Course/Institution you wish to attend:______________________________________________ Course start date:_______________________________________________________________ Institution address:______________________________________________________________ How did you learn about FAILSAFE-ERA scholarship?__________________________________ _____________________________________________________________________________
Are you a formerly incarcerated person: ___Yes ___No Are you a family member of an incarcerated person: ___ Yes ___No Applicant Signature ___________________________________ *Applicants must be a resident in Planning District 16 (Spotsylvania, Stafford, Fredericksburg, Caroline, and King George)
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
4701 Market St., Suite H Fredericksburg, VA 22408 540-479-3021
Respond to each of the following questions on separate pages. Label each page “FAILSAFEERA Scholarship Application” and include your full name. 1. How has incarceration affected you and/or your family?
2. List three community service activities you have performed.
3. How do you think the FAILSAFE-ERA scholarship program will assist you in achieving your life goals? Please limit your response to no more than 500 words.
4. Please provide two Letters of Recommendation in support of your application for the FAILSAFE-ERA scholarship program. You may select anyone from your local community who you believe can best address your personal character, commitment to community service and leadership qualities.
Please forward application materials to: FAILSAFE-ERA 4701 Market St., Suite H ATTN: Scholarship Committee Fredericksburg, VA 22408
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
4701 Market St., Suite H Fredericksburg, VA 22408 540-479-3021
Submitting an Application
How to Apply Please submit a completed application form along with two Letters of Recommendation as noted in the application. The application form is available online as a PDF document at the FAILSAFE-ERA website. Review the Application Checklist section of the application for a complete listing of required and optional attachments. Applicants may be asked to participate in an interview with the scholarship review committee. Scholarship Application Deadline: March 1, 2016
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
4701 Market St., Suite H Fredericksburg, VA 22408 540-479-3021
APPLICANT CHECKLIST
Please attach the following to your Application Form: _________ Letter of Reference _________ Second Letter of Reference _________ Letter from current employer _________ Written proof of full cost for course/materials _________ Essay on how FAILSAFE-ERA scholarship will impact your life ( no more than 500 words)
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
Scholarship Application Date of Application:_____________
NAME:________________________________________________________________________ ADDRESS:_____________________________________________________________________ ______________________________________________________________________________ PHONE (C):_________________________ PHONE (H):__________________________________ CURRENT EMPLOYER:_____________________
PHONE:___________________
ADDRESS:________________________________ POSITION:_________________ ________________________________________
DATE EMPLOYED:____________________
Course/Institution you wish to attend:______________________________________________ Course start date:_______________________________________________________________ Institution address:______________________________________________________________ How did you learn about FAILSAFE-ERA scholarship?__________________________________ _____________________________________________________________________________
Are you a formerly incarcerated person: ___Yes ___No Are you a family member of an incarcerated person: ___ Yes ___No Applicant Signature ___________________________________ *Applicants must be a resident in Planning District 16 (Spotsylvania, Stafford, Fredericksburg, Caroline, and King George)
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
4701 Market St., Suite H Fredericksburg, VA 22408 540-479-3021
Respond to each of the following questions on separate pages. Label each page “FAILSAFEERA Scholarship Application” and include your full name. 1. How has incarceration affected you and/or your family?
2. List three community service activities you have performed.
3. How do you think the FAILSAFE-ERA scholarship program will assist you in achieving your life goals? Please limit your response to no more than 500 words.
4. Please provide two Letters of Recommendation in support of your application for the FAILSAFE-ERA scholarship program. You may select anyone from your local community who you believe can best address your personal character, commitment to community service and leadership qualities.
Please forward application materials to: FAILSAFE-ERA 4701 Market St., Suite H ATTN: Scholarship Committee Fredericksburg, VA 22408
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
4701 Market St., Suite H Fredericksburg, VA 22408 540-479-3021
Submitting an Application
How to Apply Please submit a completed application form along with two Letters of Recommendation as noted in the application. The application form is available online as a PDF document at the FAILSAFE-ERA website. Review the Application Checklist section of the application for a complete listing of required and optional attachments. Applicants may be asked to participate in an interview with the scholarship review committee. Scholarship Application Deadline: March 1, 2016
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
4701 Market St., Suite H Fredericksburg, VA 22408 540-479-3021
APPLICANT CHECKLIST
Please attach the following to your Application Form: _________ Letter of Reference _________ Second Letter of Reference _________ Letter from current employer _________ Written proof of full cost for course/materials _________ Essay on how FAILSAFE-ERA scholarship will impact your life ( no more than 500 words)
““PRIVACY ACT INFORMATION—The information collected herein is FOR OFFICIAL USE ONLY and protected in accordance with the Privacy Act of 1974
