Name _________________________________________
Address _______________________________________
Telephone number _______________________________
Social Security Number ____________________________
Birth date _____________________________________
Father's Name __________________________________
Father's Occupation ______________________________
Mother's Name _________________________________
Mother's Occupation _____________________________
Brothers and Sisters (names and ages)
High School ___________________________________
Telephone Number ______________________________
Address ______________________________________
Choice of College:
1. __________________________________________
2. __________________________________________
3. __________________________________________
Extracurricular Activities*
Community Service Activities* _______________________
Awards and Honors*
Personal essays:
1. Submit a double-spaced (maximum of two pages) essay addressing one or more of the following points
a. Tell why you want to be a mathematics teacher.
b. Describe any special talent, ability, or skill you possess that will help you become an effective teacher.
c. Describe how one of your teachers has influenced your career goals.
2. Submit a paragraph explaining your need for financial aid.

This application must be accompanied by one copy of your high school transcript through the first semester of the senior year, a school profile, a copy of your scores on the SAT or the ACT, and three letters of recommendation from the Presidential Awardee who nominated you, from another mathematics teacher who has had you in class or worked with you on extracurricular activities, and from a guidance counselor or school administrator.

*Attach additional sheet if necessary
Certification: By my signature, I certify that all of the information given by me on this form is true and complete to the best of my knowledge.
Signature of Applicant _____________________________________________
Date __________________________
Signature of Awardee _____________________________________________
State/Year _____________________________________________

Return to:
Kris A Warloe, Chair
Denise I. Griffiths CPAM Scholarship Committee
1260 NW Lewisburg Ave.
Corvallis, Oregon 97330
DEADLINE: March 1, 2017 | Download Version: Word | PDF