in partnership with CONFIDENTIAL APPLICATION • • • • • • Your information will be kept confidential except to screen and review the information for award We release your name for post-award publicity only if award is given. (5) Conference Scholarships will be awarded to Corporate Planners in the meetings industry. Scholarship will include conference registration, hotel accommodations, airfare and daily per diem stipend up to $2,800 per scholarship award. Scholarship application deadline is May 25, 2013. Scholarship award notifications will be made on June 8, 2013 via email. Section I: About You * First Name: * Last Name: * MPI Member #: * Employer: (enter N/A if not currently employed) * Home Address: * City: * State/Province: * Postal Code: * Country: * E-mail: * Day Phone: Alternative Phone: URL: (enter your web address if you have a personal web site) (Only the information below this area will be submitted to the review committee.) Section II: About Your History * Membership Type: * Gender: * # Years In Meeting Industry: # Years with MPI: CURRENT Employment Information If you are a business owner, indicate the number * Employment Status: of employees in your firm: * Current Employer: (enter N/A if not currently employed) Current Title: Role / Major Responsibilities: Position You Report To: Number of positions this person is from the top: IMMEDIATE PAST Employment Information If you were a business owner, indicate the * Employment Status: number of employees in your firm: Past Employer: Past Title: Role / Major Responsibilities: Position You Reported To: Number of positions this person was from the top: FINANCIAL & HOUSEHOLD Information * Total Household Income: *No. of Children: * Child care?: * Sole Provider?: PRIOR EDUCATION *# Years of college: Completed Degrees: Major Institution Year *In the space allowed, please describe or list; 1) Other formal or informal education/certification or experience which is important for us to know. Provide year and institution when appropriate, but do not include individual workshops or other related short sessions. Examples to list would be an employer-related Executive Development Program or an all-day or more leadership event; 2) Leadership experience in your life in general. Items to include would be leadership you have or are involved with in community, church or school. Or, if you have not had the opportunity to lead yet, how do you intend to do so? Section III: About Your Plans In a few words, please tell us; 1) What your dreams are, what you hope to accomplish and how you hope to get it; 2) How you plan to give back, or lead your business community to demonstrate the value of the money given to you by MPI; and 3) How you plan to contribute to the Meeting and Events Industry. *Your Goals: *Amount Requested: $ Please be specific. For example, full-(or part-time) tuition for one semester in the amount of $XXXX. Or program fee in the amount of $XXXXX. *Scholarship will be used for: *Category(s) of Funding: If you selected COLLEGE RELATED above, answer the following questions: Accepted in: Offered by: Date: Name of course, program or class: Name of institution or organization offering the course: Enter the starting date of study/date of program: Name & phone number (or e-mail) of person who can verify your Verification acceptance in course or program: Information: If you selected OTHER PROGRAM above, answer the following questions: Name of leadership course, program or class: Wish to attend: Name of institution or organization offering the course: Offered by: Date: Enter the starting date of study: If this course leads toward certification, list certification and sponsoring Certification? agency: Online Course?: Name & phone number (or e-mail) of person who can verify the advanced nature of the course or program: Verification Information: If you selected MPI PROGRAMS above, answer the following questions: MPI Program: If you selected MPI Online Course or Other above, please explain: PAYMENT Information: *Payment Due Date: *Make Check Payable To: *Address: *Contact Name / Phone / E-mail: Section IV: About Why You Need This Scholarship In the space allotted here, please tell us why you need this scholarship: _______ I attest to the authenticity of the submitted information to the best of my knowledge. REMEMBER TO SUBMIT YOUR TAX FORMS. IMPORTANT: Print or save a copy and then e-mail to CPerry@mpiweb.org