PALM BEACH COUNTY CLASSROOM TEACHERS ASSOCIATION

BARRY M. GRUNOW MEMORIAL SCHOLARSHIP

SCHOLARSHIP ADVANCED DEGREE APPLICATION
COMPLETE THIS FORM AND RETURN TO: CTA, 715 Spencer Drive, West Palm Beach, Fl
33409 Attn: Member Scholarship
1. Name___________________________________________________________________
Last

First

Middle

2. Permanent Local Address:___________________________________________________

Street

____________________ ___________________________________________________
Home Phone #

City

State

Zip Code

E-Mail:________________________________

3. Personal Information:_______________________________________________________
Social Security Number

4. Are you employed at the present time? _________YES

_________NO
Current School Employment Location: _________________________________________
5. Dates of Employment: From: _____ To: 20____
6. Continuous Years as Member of CTA: ________________________________________
7. I will be attending college classes during the school year 2013/2014:
8. Active Service in CTA: (check those that apply)
______ Faculty Representative
______ Faculty Head/Lead Representative
______ Committee (CTA) Member
______ CTA Committee Chair
______ Other

YES ___________

School Location/Committee
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________

9. College attending:_____________________________________________________________
10. Degree working towards:______________________________________________________
11. Subject of Degree Program:____________________________________________________
12. Signature:__________________________________________________________________
APPLICATION DEADLINE April 20, 2013