LOCALS 175 & 633 MCKAY-THOMPSON-HOEBINK-GIBSON SCHOLARSHIP APPLICATION FORM
Applicant Information
First Name:
Last Name:
E-mail:
Permanent Home Address:
City:
Province:	Select... Ontario Northwest Territories Nunavut Quebec Newfoundland Prince Edward Island Nova Scotia New Brunswick Manitoba Saskatchewan Alberta British Columbia Yukon
Postal Code:
Telephone:	()   -
I am a member of UFCW Local 175 or 633
I am the of a UFCW Local 175 or 633 member If applicant is not a member, specify relationship of applicant to member here (i.e. son, daughter or spouse)
UFCW Local 175 or 633 Membership Information
Member's First Name:
Member's Family Name:
Member Since:	Select year...196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010
Employer:
Unit #:	(if applicable)
Education Information
My last completed year of schooling was . The school I last attended was . I will be studying in a program at (post-secondary institution).
Field of study:
Academic Year:
From:	Select month...JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember    Select year...20102011201220132014
To:	Select month...JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember    Select year...20102011201220132014
Expected cost of tuition:
I hereby certify that the above information is correct.
Date: 10-03-2010.