Gerald Wayne Potts Jr. Memorial Scholarship application

Gerald Wayne Potts, Jr. Scholarship Application

Instructions

Dear Scholarship Applicants:

This is the Gerald Wayne Potts Jr. Memorial Scholarship application for . We are currently accepting applications for consideration.

To be eligible you must meet the following criteria:

1. Be the child, or stepchild of a current or deceased USPCA, Region III member.
2. Be attending a two or four year college full-time in the academic calendar
year in pursuit of a Technical, Associates or Bachelors degree.
3. If selected, a scholarship in the amount of $2,500 will made to the recipient.
4. All applications should be received in complete form by . Applications
should be mailed to:
5. Scholarship Recipient Can Only Apply Once.

USPCA Region 3
C/O Gerald Potts Jr. Memorial Scholarship
6503 Rose Hill Dr, Alexandria, Va. 22310

Criteria include grades, essay responses and community service. Please feel free to make
copies of this application for your school or department. If there are any questions please
contact Carlos Rolon, President, USPCA Region III at president@uspca3.com.

Full Name *

If you have a middle name please include it.

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

Date of Birth

Name of High School

Address of High School

Country

City

State

Zip code

Mother’s Name

Father’s Name

Guardian Name

Mother Employer

Father Employer

Name of police department to which parent is/was assigned.

Indicate the person who is associated with the information requested above and dates of employment.

Status of association noted above: (check one)

Active

Deceased

Please list any children in your family that are currently attending schools

Child 1 Name

Child 1 Age

Child 1 School

Child 1 Year

Child 2 Name

Child 2 Age

Child 2 School

Child 2 Year

Child 3 Name

Child 3 Age

Child 3 School

Child 3 Year

College Information

List the names and addresses of colleges or institutions to which you have applied or intend to apply, or the name of the college or institution in which you are currently enrolled.

Institution 1 Name

Institution 1 Address

Apt, suite, etc.

Country

City

State

Zip code

Accepted ?

Institution 2 Name

Institution 2 Address

Apt, suite, etc.

Country

City

State

Zip code

Accepted ?

Institution 3 Name

Institution 3 Address

Apt, suite, etc.

Country

City

State

Zip code

Accepted ?

Have you selected a major?

If Yes, What is your major?

Academic Details

Please feel free to upload a document to answer the following questions if you need more space.

Academic Details Upload

List and describe any and all honors, prizes and/or awards that you have won to date.

Describe any volunteer activities you may have done over the years.

List any extracurricular activities detailing your participation and time spent on each.

What are your favorite leisure time activities?

Please attach copies of the following information to this application

1. Most recent transcript of grades showing all high school grades to date. This may be an
unofficial transcript that can be verified.
2. Any college letters of acceptance received.
3. If you are already enrolled as a full time college student, please include your college
transcripts to date.
4. A ONE PAGE essay addressing the following topic:
What does it mean to you to be a child of a police officer?

Information Upload

Acknowledgement

I hereby certify that the aforementioned information is true to the best of my knowledge. I
understand that any willful misrepresentation of any fact can and will disqualify me from
consideration. I understand that the deadline for submitting my completed application is March 31, 2018.

Applicant Signature

Reset Signature

Parent/Guardian Signature

Reset Signature

Gerald Wayne Potts Jr. Memorial Scholarship application

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