Nevada CUPA-HR Scholarship Application
Applicant Information
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
City
Phone:
(
State
)
ZIP Code
E-mail Address:
Current Employer
Current Position Title
Is your employer a Nevada CUPA -HR
Member?
Do you work in Human Resources?
YES
NO
Is the Institution a CUPA National
Member?
YES
NO
Describe below your current job duties and/or
how your work interfaces with HR.
YES
NO
Scholarship Request Information
Name of Event
Date(s) of Event
Registration Fee
Materials
Transportation
Lodging
Test Fees
Other (specify)
Total Amount Requested
Describe how you and your institution will benefit from this opportunity. (can provide on a separate sheet)
Describe your involvement in Nevada CUPA-HR.
If you would like to become more involved in Nevada CUPA-HR, please indicate your interest in the following activities:
Committees
Website
Leadership Role
Event Planning
Speaker
Newsletter
CUPA and Other Awards
Have you received a CUPA-HR Scholarship
in the past?
YES
NO
If so, provide the dates, awards and details.
Please list below the name and amount of other grants or scholarships you have been awarded in the last five years
Name of Award
Amount
Date
Pending
Activities & Honors
List all extra activities in which you have participated during the past five years. List all community activities in which you have
participated without pay during the past five years. Indicate all special awards, honors and offices held. Be sure to note any activities
related to HR. (can provide on a separate sheet)
Certification/Professional Licenses
Please list any certifications, professional licenses that you may have. (such as: SPHR, PHR, CCA, CCP, CPA, CBP)
Goals
Make a statement of your plans as they relate to your educational and human resource career objective and future goals. (can
provide on a separate sheet)
Unusual Factors
Please describe how and when any unusual circumstances have affected your achievement in education, work experience, or your
participation in professional and community activities and how did you over come these. (can provide on a separate sheet)
Disclaimer and Signature
I certify that my answers are true and complete to the best of my knowledge. If requested, I agree to give proof of
information I have given on this form.
Signature:
Date:
For Completion by Scholarship Review Committee
Approved
Signature:
Amount $:
Disapproved
Date:
Reason: