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Carolinas District Scholarship Application

International Convention 2013 - Vancouver, BC

Directions: Please fill out the information below and submit the application via email to

carolinascirclek@gmail.com by 11:59pm March 31st, 2013. Late applications will not be accepted;

Recipients will be notified by April 6th. The selected recipients of this scholarship will register forInternational Convention online, send proof of registration (e.g. a copy of the confirmation email), then

a reimbursement check will be sent.

As a requirement of this scholarship, you will have to serve as a delegate at the House of

Delegates at International Convention. Please confirm that you understand this

requirement by typing an X in the box below.

Yes I understand this requirement. I will serve as a voting delegate for my club.

Basic Information Answer all items that apply to you.

Name:Gender: Current Officer Position(s):

Mobile phone #: Email:

College/University: Expected Year of Graduation:

Circle K Division: Circle K Member Number:

This scholarship is designed to assist outstanding Circle K members in attending InternationalConvention to better their home clubs, vote in matters that shape the entire organization andrepresent the Carolinas District to international. To apply for the scholarship you must be a duespaid member and be approved by your club to serve as a voting delegate for your club at theHouse of Delegates 2013 at the Convention. The scholarship is for a maximum amount of $185,the cost of Early Bird Registration to International Convention registration which due by April 15.

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Have you attended ICON before? Please listwhich year(s).

How many years have you been in Circle K?

Summer or Permanent Address:

Additional Information Please place answers in the space provided below

Circle K offices held and what year (elected or appointed positions on the club, district,or international level):

Circle K leadership events attended (district or international conventions, trainingconferences, or leadership events):

Why do you wish to attend International Convention 2013? [250 words max]

How do you think attending International Convention will better your club? [If a senior:How do you think attending International Convention will better your leadership skills?]

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By submitting this form and typing my name on the line below, I agree to attend InternationalConvention in Vancouver, BC June 26-30, 2013 if selected to receive the scholarship for which I amapplying.

_______ _______Applicants name