IPA Program Scholarship Application
(To apply
for a scholarship, print out this form from your Web browser.
Then fill in the requested information and mail it to the address given below.)
The information collected below shall be kept confidential and will not be disclosed outside of the IPA Scholarship Committee without your consent.
1. Name (please print) ___________________________________________________________
2. Current address_______________________________________________________________
City ________________________________ State/Prov. _______________________________
Country _____________________________ Zip/P.Code _______________________________
Telephone _____________________________ Email __________________________________
3. Marital status:
4. Number of dependents (living at home):
Are you the sole provider in the household?
5. Employer's name and address:
6. Total yearly family income:
To be eligible for this scholarship, your total yearly income must fall within the following guideline requirements. The figures are in US dollars. Circle one:
a) Single: $20,420 b) One Dependent: $23,900 c) Two Dependents: $27,380
d) Three Dependents: $30,860 e) Four Dependents: $34,340
7. Please state the reason that you would like to attend IPA events (use extra paper if necessary).
The information provided is true and complete. I understand that any willful misstatement of fact will be grounds for disqualification.
_____________________________________________
Applicant signature
____________________________________________
Date
International Primal Association,
811
Whann Avenue, McLean,
VA 22101,