S.A.E.Y.C. Scholarship Application and Agreement
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Date of Application ______/______/______
Applicant's Name ________________________________________________________________
Home Address ________________________________________________________________
  __________________________________________, WI __________________
Home Phone (920) ________-_____________
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Name of Employer ________________________________________________________________
Work Address ________________________________________________________________
  __________________________________________, WI __________________
Work Phone (920) ________-_____________
Job Title ________________________________________________________________
Supervisor's Name ________________________________________________________________
Short Job Description:  
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Does your employer contribute to your continuing education?   _____ Yes       _____ No
If yes, how much? Total dollar amount per year      $__________.______ or
  Percentage                                  ___________%
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Name of training/conference you would like to attend -
______________________________________________________________________________________
Date(s) of attendance - ______/______/______ (through ______/______/______)
Location ________________________________________________________________
  ________________________________________________________________
  _______________________________________, _________  ______________
Sponsored by ________________________________________________________________
Cost of the training/conference            $__________.______
Amount funded by other sources         $__________.______
Amount you are requesting                  $__________.______
Date payment is needed                        ______/______/______
Check should be made payable to ___________________________________________________________
How will this training/conference improve your professional skills?
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______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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I have read the requirements and guidelines of the S.A.E.Y.C. Scholarship Fund and agree to abide by all guidelines. If I do not complete or attend the training/conference, I understand that I will be responsible to repay S.A.E.Y.C. the entire amount I was awarded.
Signed          ________________________________________________________________
Dated           ______/______/______
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