UCPBA of OTTAWA SCHOLARSHIP

Application Form & Document Checklist

Year of application: _______

Name (first, middle, last): ________________________________________________________

Address: _____________________________________________________________________

City, Province, Postal Code: ______________________________________________________

Phone Number: (home) ( ___ ) ______________ Date of Birth: ________________________

E-mail: ____________________________________________

Academic Institute as of September 1st of this year, and field, program, or study major:

_____________________________________________________________________________

Names and addresses of two references (non-relatives) supporting your application. At least one individual must be familiar with your involvement in the Ukrainian Canadian community. Please arrange to have the letters mailed directly to the UCPBA Scholarship Committee.

Reference 1: __________________________________________________________________

Reference 2: __________________________________________________________________

Please check that all parts of the application have been completed and are enclosed and that your name is clearly identified on each document:

• Application form including names and addresses of two references

• Photocopy of report card or transcripts for previous academic year

• One page, single-space essay on “Revitalizing Ottawa’s Ukrainian Canadian community”

• Curriculum vitae (résumé) organized into the following sections:

• Name and address including e-mail and phone numbers

• Education (school, years, diploma or degrees completed)

• Employment (employer, duration, list of responsibilities)

• Volunteer Experience in the Ukrainian Canadian community (organization, supervisor, duration, list of responsibilities)

• Other Volunteer Experience

• Extracurricular activities

Completed applications should be sent to UCPBA Ottawa Scholarship Committee, 913 Carling Avenue, Ottawa, ON K1Y 4E3 postmarked no later than October 31st.

Signature of applicant ______________________________ Date ________________________