PFFSD Michael D Anderson Memorial Scholarship
Official Application Form
 
(Please Print)
 
  1. Applicant’s Name___________________________________________________
 
Address___________________________________________________________
 
____________________________________ Phone: _______________________
      (City)         (State)              (Zip)
 
  1. Date of Birth_________________________
 
  1. Name of  High School________________________________________________
 
  1. Graduation Date/GED Date___________________________________________
 
  1. Name of enrolled Secondary School_____________________________________
 
  1. Program enrolled in__________________________________________________
 
 
________________________________________                __________________
                (Applicant’s Signature)                                                               (Date)
 
 
  1. Name of union member_____________________________
 
Relationship______________________________________
 
Address___________________________________________________________
 
____________________________________ Phone: _______________________
      (City)         (State)              (Zip)
 
  1. Local Union Name__________________________________________________
(Attach proof of membership in good standing signed by local union officers)
 
 
 
  1.  _____________________________________        (Date)_________________
   Union Members Signature
     (If deceased print name)
 
 
 
 
* NOTE: The applicant must sign the following statement.
 
 
                        I hereby indicate my understanding that the decision of the PFFSD Scholarship Committee in the selection of the scholarship winner is final and binding on all applicants. I understand that the union reserves the right at any time without giving reason, to terminate, cancel, or end the program provided that scholarships or awards already granted and/or announced shall run to the end of the promised and publicly stated.
 
I agree that should I become a successful candidate for the Michael D Anderson Memorial Scholarship, I shall comply with all rules and regulations set down by the Professional Firefighters of South Dakota (PFFSD) Executive Board for such scholarship. I understand that continuation of said scholarship shall be conditioned on evidence of satisfactory academic performance.
 
            In the event I am selected winner of the Professional Firefighters of South Dakota Michael D Anderson Memorial Scholarship, I hereby give permission to the PFFSD to publish my name and photo as a winner of the scholarship.
 
 
 
________________________________________                      __________________
                (Applicant’s Signature)                                                               (Date)
 
 
 
 
 
 
 
 
 
 
 
Applications shall be mailed to the Professional Firefighters of South Dakota President:
 
Rob Senger
Professional Firefighters of South Dakota Inc,
126 South Shore Dr.
Mina, SD 57451
 
 
 
 
PFFSD Michael D Anderson Memorial Scholarship
 
Proof of Union Membership
 
 
 
_______________________is a member in good standing of Local#__________
(Name)           
 
                                                                                               
 
 
                                                                       
 
 
____________________________________
                                                                        Local President
 
 
 
 
 
 
                                                                        ____________________________________
                                                                        Local Secretary
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
* IAFF Local Seal *