The Delta Kappa Gamma Society International

California State Scholarship Committee

Area X Stipend/Grant

Date __________________________

I. PERSONAL INFORMATION

Name _____________________________________________________

Address ___________________________________________________

City ______________________ State _______ Zip _________ Email

Home Phone (____)______________ Work Phone (____) ______________

Present Professional Position ________________________________

Have you made an application for a stipend in the last two years? Yes No

II. DELTA KAPPA GAMMA INFORMATION

Current Chapter ____________________________________ Area ________________

Offices/Chairmanships (last two years)

Position/Committees Level: Chapter/Area/State/International

Conventions/Conference Level: Chapter/Area/State/International

I certify that the information provided in this application is correct and that I am forwarding
one set of the completed application to:

Signature of Applicant Date

Send this application to:

Dana Maybury
Awards Chairman
2671 Fieldbrook Way
Escondido, CA 92027
danamaybury@gmail.com

Created March 2016